Bianca Calabria - UNSWorks

Creating partnerships between researchers, health care

providers and Indigenous Australians to improve

Indigenous health: a demonstration model

Bianca Calabria

BPsych(Hons)

A thesis in fulfilment of the requirements for the degree of

Doctor of Philosophy

National Drug and Alcohol Research Centre

School of Public Health and Community Medicine

Faculty of Medicine

University of New South Wales

August 2013

i

Originality Statement

I hereby declare that this submission is my own work and to the best of my knowledge it

contains no materials previously published or written by another person, or substantial

proportions of material which have been accepted for the award of any other degree or

diploma at UNSW or any other educational institution, except where due acknowledgement is

made in the thesis. Any contribution made to the research by others, with whom I have

worked at UNSW or elsewhere, is explicitly acknowledged in the thesis. I also declare that the

intellectual content of this thesis is the product of my own work, except to the extent that

assistance from others in the project's design and conception or in style, presentation and

linguistic expression is acknowledged.

Bianca Calabria August 2013

ii

Copyright Statement

I hereby grant the University of New South Wales or its agents the right to archive and to

make available my thesis or dissertation in whole or part in the University libraries in all forms

of media, now or here after known, subject to the provisions of the Copyright Act 1968. I

retain all proprietary rights, such as patent rights. I also retain the right to use in future works

(such as articles or books) all or part of this thesis or dissertation. I also authorise University

Microfilms to use the 350 word abstract of my thesis in Dissertation Abstract International

(this is applicable to doctoral theses only). I have either used no substantial portions of

copyright material in my thesis or I have obtained permission to use copyright material; where

permission has not been granted I have applied/will apply for a partial restriction of the digital

copy of my thesis or dissertation.

Bianca Calabria March 2014

iii

Authenticity Statement

I certify that the Library deposit digital copy is a direct equivalent of the final officially

approved version of my thesis. No emendation of content has occurred and if there are any

minor variations in formatting, they are the result of the conversion to digital format.

Bianca Calabria March 2014

iv

Supervisor Statement

I hereby certify that all co-authors of the published or submitted papers agree to Bianca

Calabria submitting those papers as part of her doctoral thesis.

Anthony Shakeshaft August 2013

Thesis by Publication Statement

Six papers are included in this thesis by publication. Four papers have been published in peer-

reviewed journals and two papers have been submitted for editorial review to peer-reviewed

journals. I attest to the publishable quality of the two papers currently under editorial review.

Anthony Shakeshaft August 2013

v

Acknowledgements

Firstly, I would like to thank my supervisors Anthony Shakeshaft and Anton Clifford for their

dedicated supervision. Through working with Anthony and Anton over the duration of my

candidature I have learnt about the kind of researcher I aspire to be. I would like to thank

Anthony for his enthusiasm for research which motivated me to get through the next stage of

thesis writing. Anthony’s flexibility, compassion, and dedication to teaching have helped me to

develop my research skills on many levels. I am grateful for the ongoing discussions Anton and

I had about the day by day project challenges. Anton’s drive, open mindedness and

commitment have taught me to look for the benefit in the unexpected hurdles of research. I

would also like to thank my co-supervisor Christopher Doran for helping to develop my

research skills and professional networks, which will be a part of my career in academia in the

years to come.

I would like to thank the co-authors on the six published papers that constitute my thesis:

Julaine Allan, Donna Bliss, Anton Clifford, Kate Conigrave, Christopher Doran, Wayne Hall, Alys

Havard, Miranda Rose, Anthony Shakeshaft, Lynette Simpson, and Theo Vos. The contributions

made by each have improved the content of the co-authored papers, and therefore my thesis.

I would also like to thank Mark Deady, Joanne Gilsenan, Melissa Haswell-Elkins, Sonja

Memedovic, Tim Slade, Chiara Stone, and Komla Tsey who provided input into this research.

Thank you to the Aboriginal people involved in this research. As this thesis demonstrates, input

from Aboriginal people is imperative for Aboriginal-specific research. I value the time they

volunteered and the conversations we had, in addition to the comments and suggestions they

provided about the research project.

vi

I am grateful to the staff of Yoorana Gunya Family Healing Centre and the Lyndon Community

who were involved in this research. This research would be nothing without their commitment

and dedication to achieving the project’s goals. I would like to especially thank the counsellors

who worked so hard to be trained and certified in the interventions.

I am grateful to the National Drug and Alcohol Research Centre (NDRAC) for providing a

supportive environment during my candidature and the opportunity for me to work closely

with many talented researchers. Thank you to NDARC, the National Health and Medical

Research Council, the Australian Research Council, the Australian Government Department of

Health and Ageing, and the Alcohol Education and Rehabilitation Foundation for providing

funding that supported this research.

To my loving family and friends, thank you for everything you have done to help me get

through my candidature; the listening ear, the needed distraction, and the child minding all

helped me to complete my thesis. I’d especially like to thank my husband and my son for their

understanding when I was absorbed by my research, and for their constant love and support.

vii

Abstract

Alcohol misuse imposes a disproportionately high burden of harm on Indigenous Australians.

Alcohol-related harms affect the physical, psychological, and spiritual wellbeing of Indigenous

Australians. Harms extend beyond the problem drinker to their families and communities.

The primary aim of this thesis was to develop and implement a process of researchers, health

care providers and Indigenous Australians working in partnership to more effectively respond

to the deleterious impact of alcohol misuse on Indigenous families and communities. The

process was highly interactive in that it sought to combine the methodological skills of

researchers, the clinical knowledge and skills of health care providers, and the community

knowledge and experience of Indigenous Australians. Specifically, research was used to

identify interventions with potential to address alcohol-related harms that could be tailored to

be consistent with Indigenous Australians’ concepts of health and wellbeing (Papers 1 and 6),

to ensure the reliability and validity of potential measures of impact (Paper 2), and to identify

more precisely the nature of alcohol-related harm experienced by Indigenous Australians

(Paper 5). Indigenous Australians’ perceptions of the acceptability of potential interventions

were obtained (Paper 4). Health care providers’ views on how the potential interventions

might best be tailored for routine delivery (Paper 3), and on undertaking a certification process

to improve and standardise their skills in delivering the potential interventions (Paper 3), were

also obtained.

This thesis is presented for examination as a series of publications, which means it presents a

series of papers that were published in, or submitted for editorial review to, a peer-reviewed

journal during the student’s candidature, rather than the traditional model of presenting thesis

chapters. Consistent with the University of New South Wales’ thesis requirements, preambles

viii

have been added to the papers to facilitate a coherent logical flow across the thesis, and

appendices are included to complement the published content, but otherwise the papers are

unaltered from the published or submitted versions. Papers 1, 4, 5 and 6 are published and

Papers 2 and 3 are currently under editorial review. The introduction, and the implications and

future directions chapter, provide a broader context for this thesis.

1

Table of Contents

Originality Statement i

Copyright Statement ii

Authenticity Statement iii

Supervisors Statement iv

Thesis by Publication Statement iv

Acknowledgements v

Abstract vii

List of Tables 5

List of Figures 7

List of Abbreviations 8

List of Presentations 10

Introduction 13

Paper 1: A systematic review of family-based interventions targeting alcohol misuse

and their potential to reduce alcohol-related harm in Indigenous communities

28

Copyright statement 29

Preamble 30

Abstract 31

Introduction 32

Method 34

Results 39

Discussion 53

Paper 2: Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut-off scores for at-risk,

high-risk and likely dependent drinkers using measures of agreement with the 10-item

2

Alcohol Use Disorders Identification Test 58


Preamble 60

Abstract 62

Background 63

Methods 64

Results 69

Discussion 75

Paper 3: Tailoring a family-based alcohol intervention for Aboriginal Australians, and

the experiences and perceptions of the health care providers trained in its delivery

80


Preamble 82

Abstract 84

Introduction 85

Methods 86

Results 94

Discussion 102

Paper 4: The acceptability to Aboriginal Australians of a family-based intervention to

reduce alcohol-related harms

107


Preamble 109

Abstract 110

Introduction 111

Methods 112

Results 114

3

Discussion 117

Paper 5: Epidemiology of alcohol-related burden of disease among Indigenous

Australians

121


Preamble 123

Abstract 124

Introduction 125

Method 126

Results 129

Discussion 133

Paper 6: A systematic and methodological review of interventions for young people

experiencing alcohol-related harm

137


Preamble 139

Abstract 140

Introduction 141

Method 143

Results 148

Discussion 160

Implications and future directions 167

References 181

Appendix A: Search strings for systematic search for family-based alcohol

interventions

216

Appendix B: Formulae for analysis 218

Appendix C: Health care provider consent form 219

4

Appendix D: Qualitative data analysis 223

Appendix E: CRA and CRAFT intervention resources 242

Appendix F: Advertising poster for recruitment for the acceptability study 264

Appendix G: Acceptability survey information for participants 265

Appendix H: Intervention information and acceptability survey 268

Appendix I: Slides used to present the acceptability survey in a standardised manner 289

Appendix J: Group record sheet for acceptability survey 351

Appendix K: Additional methods and results not included in the published paper

(Calabria et al. 2013)

352

Appendix L: Search strings for systematic search for interventions addressing

problematic alcohol use among young people

360

5

List of Tables

Paper 1: A systematic review of family-based interventions targeting alcohol misuse and their

potential to reduce alcohol-related harm in Indigenous communities

Table 1: Family-based interventions for problem drinkers and/or their family

members

41

Table 2: Methodological adequacy 50

Paper 2: Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut-off scores for at-risk, high-risk

and likely dependent drinkers using measures of agreement with the 10-item Alcohol Use

Disorders Identification Test

Table 1: Alcohol Use Disorders Identification Test (AUDIT) adapted wording for

Aboriginal Australians

66

Table 2: Measures of agreement for AUDIT-C and AUDIT-3 cut-off scores 71

Paper 3: Tailoring a family-based alcohol intervention for Aboriginal Australians, and the

experiences and perceptions of the health care providers trained in its delivery

Table 1: Health care providers’ role and qualifications 91

Table 2: Focus of working group meetings 92

Paper 4: The acceptability to Aboriginal Australians of a family-based intervention to reduce

alcohol-related harms

Table 1: Demographic characteristics of the sample (n = 116) 115

Table 2: Preference for intervention delivery 116

Paper 5: Epidemiology of alcohol-related burden of disease among Indigenous Australians

Table 1: Rates (DALYs per 1,000) of alcohol-related disease and injury, Australia 131



Table 1: Interventions for young people experiencing alcohol-related harm 150

6

Table 2: Methodological adequacy of reviewed studies 156

7

List of Figures

Paper 1: A systematic review of family-based interventions targeting alcohol misuse and their

potential to reduce alcohol-related harm in Indigenous communities

Figure 1: Flowchart indicating search strategy and classification of articles 35

Paper 2: Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut-off scores for at-risk, high-risk

and likely dependent drinkers using measures of agreement with the 10-item Alcohol Use

Disorders Identification Test

Figure 1: ROC curve for at-risk drinker (AUDIT score ≥ 8) 72

Figure 2: ROC curve for high-risk drinker (AUDIT score ≥ 13) 73

Figure 3: ROC curve for likely dependent drinker (AUDIT score ≥ 20) 74

Paper 3: Tailoring a family-based alcohol intervention for Aboriginal Australians, and the

experiences and perceptions of the health care providers trained in its delivery

Figure 1: Process of tailoring the CRA and CRAFT interventions 88

Paper 5: Epidemiology of alcohol-related burden of disease among Indigenous Australians

Figure 1: Alcohol-related disease and injury by sex: males 132

Figure 2: Alcohol-related disease and injury by sex: females 132



Figure 1: Flowchart indicating search strategy and classification of articles 145

8

List of Abbreviations

In each chapter/paper, abbreviations are used after the phrase has been written in full.

A-CRA Adolescent Community Reinforcement Approach

ACCHS Aboriginal Community Controlled Health Service

AH&MRC Aboriginal Health and Medical Research Council

AQoL-6D Assessment of Quality of Life – 6D

ARISE A Relational Sequence for Engagement

AUROC Areas under the receiver operating characteristic

AUDIT Alcohol Use Disorders Identification Test

AUDIT-C First three items of AUDIT

AUDIT-3 Third item of AUDIT

BMI Brief motivational interviewing

CBT Cognitive behavioural therapy

CI Confidence interval

CRA Community Reinforcement Approach

CRAFT Community Reinforcement and Family Training

CRAFFT Car Relax Alone Forget Friends Trouble

CVD Cardiovascular disease

DALY Disability adjusted life year

DAST Drug Abuse Screening Test

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Volume 4

DUI Driving under the influence

etc. Et cetera

e.g. For example

Fig. Figure

9

g Grams

GEM Growth Empowerment Measure

HIV Human immunodeficiency virus

HREC Human Research Ethics Committee

i.e. That is

MBD Multiple baseline design

MI Motivational interviewing

N/A Not applicable

NATSIHS National Aboriginal and Torres Strait Islander Health Survey

NDARC National Drug and Alcohol Research Centre

NHMRC National Health and Medical Research Council

NHS National health survey

NSW New South Wales

PAF Population attributable fraction

RCT Randomised control trial

ROC Receiver operating characteristic

SD Standard deviation

UNSW University of New South Wales

U.S. United States

YLD Year of life lived with disability

YLL Years of life lost

10

List of Presentations

1. Bianca Calabria, Anthony Shakeshaft, Anton Clifford, Komla Tsey, Julaine Allan, Christopher

Doran, Miranda Rose, Rod MacQueen. Family-based intervention for Indigenous people

who have alcohol use problems, National Drug and Alcohol Research Centre Seminar

Series, May 2010: Sydney, Australia [oral presentation].

2. Bianca Calabria, Anton Clifford, Anthony Shakeshaft, Christopher Doran. Reducing alcohol-

related harms among Indigenous Australians: A systematic review of family-based

approaches, National Drug and Alcohol Research Centre Annual Symposium, August 2010:

Sydney, Australia [poster presentation].

3. Bianca Calabria, Anton Clifford, Anthony Shakeshaft, Christopher Doran, Julaine Allan,

Miranda Rose, Komla Tsey. Family-based approaches to reduce alcohol-related harms

among Indigenous Australians, Australian Professional Society on Alcohol and Other Drugs

(APSAD) Conference, November 2010: Canberra, Australia [oral presentation].

4. Bianca Calabria, Anthony Shakeshaft, Anton Clifford, Komla Tsey, Julaine Allan, Christopher

Doran, Miranda Rose, Rod MacQueen. Development and evaluation of a family-based

intervention to reduce alcohol-related harms among Indigenous Australians: Acceptability

and study design, National Drug and Alcohol Research Centre Seminar Series, April 2011:

Sydney, Australia [oral presentation].


Miranda Rose, Rod MacQueen. The acceptability of a family-based alcohol intervention to

Indigenous clients of a rural Aboriginal Community Controlled Health Service and drug and

alcohol treatment agency, 3rd Aboriginal Health Research Conference, Coalition for

11

Research to Improve Aboriginal Health (CRIAH), May 2011: Sydney, Australia [oral

presentation].


Miranda Rose, Komla Tsey, Rod MacQueen. The acceptability of a family-based alcohol

intervention to Indigenous clients of a rural Aboriginal Community Controlled Health

Service and drug and alcohol treatment agency, University of New South Wales, School of

Public Health and Community Medicine Research Symposium, August 2011: Sydney,

Australia [oral presentation].


Miranda Rose, Komla Tsey, Rod MacQueen. A family-based approach to reducing alcohol-

related harms among Aboriginal Australians in rural New South Wales, National Drug and

Alcohol Research Centre Annual Symposium, August 2011: Sydney, Australia [oral

presentation].


Miranda Rose, Komla Tsey, Rod MacQueen. The acceptability of a family-based alcohol

intervention to Indigenous clients of a rural Aboriginal Community Controlled Health

Service and drug and alcohol treatment agency, National Drug and Alcohol Research

Centre Annual Symposium, August 2011: Sydney, Australia [poster presentation].

9. Bianca Calabria, Anton Clifford, Anthony Shakeshaft, Katherine Conigrave, Lynette

Simpson, Julaine Allan. Identifying risky and dependent Aboriginal drinkers using AUDIT-C

and AUDIT-3, National Drug and Alcohol Research Centre Annual Symposium, August

2012: Sydney, Australia [poster presentation].

12

10. Bianca Calabria, Anton Clifford, Anthony Shakeshaft, Katherine Conigrave, Lynette

Simpson, Donna Bliss and Julaine Allan. AUDIT-C and AUDIT-3 cut-off scores for Aboriginal

Australians, National Drug and Alcohol Research Centre Seminar Series, November 2012:

Sydney, Australia [oral presentation].

11. Bianca Calabria, Anton Clifford, Miranda Rose, Anthony Shakeshaft. Tailoring two

evidence-based interventions for delivery to Aboriginal Australians: Perception of, and

suggestions by, health care providers, National Drug and Alcohol Research Centre Annual

Symposium, September 2013: Sydney, Australia [poster presentation].

12. Bianca Calabria, Anthony Shakeshaft, Anton Clifford. Improving Indigenous intervention

research by establishing partnerships between researchers, Indigenous Australians and

health care providers, University of New South Wales, School of Public Health and

Community Medicine Research Symposium, October 2013: Sydney, Australia [oral

presentation].

13

Introduction

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A brief overview of Indigenous Australian history and alcohol

Indigenous Australians1 have one of the oldest continuing cultures in the world (Rasmussen et

al. 2011). They share a strong connection to their past and to their traditional lands which is

communicated through varied cultural practices (Coates 2004), both traditional and

contemporary. The colonisation of Australia and government policies and practices had, and

continues to have, a negative and significant impact on Indigenous Australians’ physical, social,

emotional and mental health and wellbeing (Gracey & King 2009). The health status of

Indigenous Australians is, therefore, worse than any other identifiable group in Australia

(Australian Institute of Health and Welfare 2011d). The socio-economic determinants of poor

health for Indigenous and non-Indigenous people include income, education, employment,

living conditions, social support and access to health care services (King, Smith & Gracey 2009).

Indigenous Australians have worse outcomes on each of these determinants compared to non-

Indigenous Australians (Altman 2003; Australian Medical Association 2011). Additionally,

Indigenous Australians’ health is negatively affected by factors inextricably linked to the

process of colonisation, such as racism, loss of language and connection to the land,

environmental deprivation, and spiritual, emotional and mental disconnectedness from culture

and community (King, Smith & Gracey 2009). The presence of these socio-economic

determinants of poor health has, in turn, been shown to be significantly associated with an

increased incidence of a number of health risk behaviours, including alcohol misuse, which has

1 Australia’s first peoples have two distinct cultural identities: Aboriginal and Torres Strait Islander

groups. The first inhabitants of Australia are referred to in this thesis as Indigenous Australians,

Aboriginal people, Aboriginal Australians, and Aboriginal and Torres Strait Islander people. Referential

terms for Australia’s first peoples vary across the chapters/papers of this thesis to represent the

preference of Aboriginal and/or Torres Strait Islander people involved in each chapter.

15

been shown to further worsen Indigenous Australians’ health status (Australian Institute of

Health and Welfare 2011d; King, Smith & Gracey 2009; Vos et al. 2007).

The colonisation of Australia had a particularly detrimental effect on alcohol consumption

patterns among Indigenous Australians. Prior to colonisation, Indigenous Australians

participated in controlled consumption of mild fermented beverages made from local plants

(Brady 1991) for ceremonial and trade purposes (Brady 2008). Alcohol was also introduced to

Indigenous Australians by Makassans, the Dutch, the French and the Russians, before the

British arrived in 1788 (Brady 2008). When the British settled in Australia, patterns of

consuming large quantities of alcohol on a single occasion were introduced (Lewis 1992) and

Indigenous Australians learned these patterns of drinking (Brady 2008). State Prohibition Laws

denying Indigenous Australians legal access to alcohol were introduced in New South Wales in

1838, Western Australia in 1843, Victoria in 1864, South Australia and the Northern Territory

in 1869, Queensland in 1885, Tasmania in 1908, and the Australian Capital Territory in 1929

(Brady 1991; Brady 2008). These laws had the effect of segregating Indigenous and non-

Indigenous drinking, effectively increasing the temptation of alcohol to Indigenous Australians,

and encouraging Indigenous Australians to get drunk very quickly in an uncontrolled

environment (Brady 2008). When prohibition eased in the 1900s, conditional citizenship, and

the legal right to drink, were restored in the legislation, but only for Indigenous Australians

who had abandoned their tribal associations, served in the armed forces, or were deemed to

have acquired the ‘habits of civilised life’ (Lewis 1992). Indigenous Australians classified as

‘mixed decent’ (that is those who were part Indigenous and part European) were also allowed

to drink alcohol (Brady 1991). The right to drink alcohol, therefore, was equated to citizenship

and assimilation with the prevailing European values and lifestyle (Lewis 1992).

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Alcohol use in Australia’s Indigenous and general populations

The National Drug Strategy Household Survey collects alcohol consumption data for

Australians aged 14 years or older. The most comprehensive and methodologically sound data

(Chikritzhs & Brady 2006) on Indigenous Australian alcohol use was collected in 1994 and is

reported in the Urban Aboriginal and Torres Strait Islander Peoples Supplement (Australian

Department of Human Services and Health 1995). This supplement compares 1994 Indigenous-

specific data to 1993 general population data. Thirty-seven percent of Indigenous Australians

reported that they did not currently drink alcohol (28% of males and 44% of females),

compared to 22% of general population Australians (16% of males and 26% of females).

Among the current drinkers, hazardous (two to four standard drinks per occasion for females

and four to six for males) and harmful (more than four standard drinks per occasion for

females and more than six for males) drinking was reported by 14% and 68% of Indigenous

respondents respectively, and 17% and 11% of general population respondents respectively.

Although limited, more recent data show a similar trend. A greater proportion of Indigenous

Australians abstain from drinking alcohol, compared to general population Australians: 21.3%

compared to 16.4% in 2004; 23.4% compared to 17.1% in 2007; and 24.5% compared to 19.5%

in 2010 (Australian Institute of Health and Welfare 2005; Australian Institute of Health and

Welfare 2008a; Australian Institute of Health and Welfare 2011a). A higher proportion of

Indigenous Australians, however, drink at levels that increase their risk of alcohol-related

harm. The proportion of those who report short-term risky alcohol consumption for

Indigenous Australians, relative to general population Australians, in 2004 (defined as the

consumption of at least seven (males) or five (females) standard drinks per occasion) was

38.7% and 20.7% respectively. In 2007 the comparable proportions were 27.4% and 20.4%

respectively. Results from 2010 showed a substantial reduction for both Indigenous and

general population Australians (24.6% and 15.9%, respectively) (defined as the consumption of

17

more than four standard drinks per occasion for both males and females). The proportion of

those who report long-term risky alcohol consumption for Indigenous Australians, relative to

general population Australians, in 2004 (defined as the consumption of at least 29 (males) or

15 (females) standard drinks in a week) was 22.7% and 9.9% respectively. In 2007 the

comparable proportions were 12.5% and 10.3% respectively. Results from 2010 showed a

large increase for both Indigenous and general population Australians (31.0% and 20.1%

respectively), although this most likely reflects the introduction of a more conservative

definition of long-term risky drinking (the consumption of at least two standard drinks on any

day for males and females) (Australian Institute of Health and Welfare 2005; Australian

Institute of Health and Welfare 2008a; Australian Institute of Health and Welfare 2011a). As a

consequence of these relatively higher proportions of both short-term and long-term risky

drinkers, Indigenous Australians experience a disproportionately high burden of alcohol-

related harm, relative to general population Australians (Begg et al. 2007; Vos et al. 2003).

Contribution of alcohol use to the burden of disease and health care costs imposed

on Indigenous Australians

The health related burden of disease is commonly measured using the Disability Adjusted Life

Year (DALY) which is equivalent to one lost year of ‘healthy’ life due to death or disability

(Murray et al. 2012). Mortality and morbidity health data are incorporated into the DALYs from

hospital records, vital registration, surveys and other sources (Vos et al. 2007). In the

Indigenous Australian population, alcohol is estimated to contribute 5.4% to the total burden

of disease (6.2% of harmful effects and -0.8% of beneficial effects) (Vos et al. 2007), compared

to 2.3% of the total burden of disease (3.3% of the harmful effects and -1.0% of the beneficial

effects) in the general Australian population (Begg et al. 2007). The greatest contributors to

the estimated alcohol-related harm among Indigenous Australians are alcohol abuse and

harmful use (40%), homicide and violence (14%), suicide (14%) and road traffic accidents (14%)

18

(Vos et al. 2003). Relative to other risk factors, alcohol is estimated as being responsible for the

greatest proportion of the burden of disease imposed on Indigenous males aged 15-34 years

and the second greatest proportion of the burden of disease imposed on Indigenous females

of the same age (eclipsed only by intimate partner violence) (Vos et al. 2003). Alcohol is also

the leading risk factor for injury among Indigenous Australians (Vos et al. 2007). In addition,

mental health disorders is estimated as being responsible for 15.5% of the total disease burden

among Indigenous Australians, 19% of which is directly associated with alcohol dependence

and harmful use (Vos et al. 2003).

As well as attempting to estimate the relative contribution of different diseases and injuries to

mortality and morbidity, the burden of disease data are used to quantify the health gap

between Indigenous and general population Australians. The health gap is defined as the

difference between the number of ‘healthy’ years of life lost through disability or death and

the number of healthy years that would have been lost if a difference between Indigenous

Australian and general Australian population disease and injury rates did not exist (Vos et al.

2009). The Indigenous health gap accounts for 59% of the total burden of disease among

Indigenous Australians. Alcohol is in the top five main risk factors and contributes 4% to the

Indigenous health gap. The other four main risk factors are tobacco (17%), high body mass

(16%), physical inactivity (12%), and high blood cholesterol (7%) (Vos et al. 2009).

The health gap is reflected in the difference in health costs for Indigenous, compared to

general population, Australians. The estimated per person expenditure on health care costs for

2008-09, for services where cost has been estimated, was $3,887.20 for Indigenous Australians

and $2,509.20 for non-Indigenous Australians (Australian Institute of Health and Welfare

2011c). Hospital separations refer to an episode of admitted patient care that is completed by

discharge, dying, being transferred to another hospital, or by change of type of care (Australian

19

Institute of Health and Welfare 2011b). Hospital separation rates (public and private) for

alcohol dependence and other harmful use during 2008-09 were 3.7 times higher for

Indigenous compared to non-Indigenous Australians (7.3 for Indigenous and 2.0 for non-

Indigenous). These hospital separations cost an estimated $17.6 million for Indigenous and

$135.9 million for non-Indigenous, translating to $32.30 for each Indigenous individual and

$6.40 for each non-Indigenous individual (Australian Institute of Health and Welfare 2011c).

Governments provided 69.7% of the total health care funding for 2008-09 with the remaining

30.3% paid by individuals, private health insurance and other non-government sources

(Australian Institute of Health and Welfare 2010). An effective government response to reduce

these harms and costs is, therefore, essential.

Closing the Gap Framework

In March 2008, the Council of Australian Governments (including the Prime Minister, State

Premiers, Territory Chief Ministers and the President of the Australian Local Government

Association) formally committed to the Closing the Gap Framework, aimed at achieving

Indigenous health equality within 25 years (Council of Australian Governments 2012). Six

specific targets were agreed: 1) closing the life expectancy gap within a generation; 2) halving

the gap in mortality rates for Indigenous children under five within a decade; 3) ensuring all

Indigenous four year olds in remote communities have access to early childhood education

within five years; 4) halving the gap for Indigenous students in reading, writing and numeracy

within a decade; 5) halving the gap for Indigenous young people attaining Year 12

qualifications or equivalent by 2020; and 6) halving the gap in employment outcomes between

Indigenous and non-Indigenous Australians within a decade (Council of Australian

Governments 2012; Australian Institute of Health and Welfare 2011d). Seven building blocks

were also defined in the Closing the Gap Framework as underpinning the achievement of the

targets: 1) early childhood; 2) schooling; 3) health; 4) healthy homes; 5) economic

20

participation; 6) safe communities; and 7) governance and leadership. Among other things, the

‘health’ and ‘safe communities’ building blocks are aimed at reducing alcohol-related harms

among Indigenous Australians by expanding health care services for alcohol dependence and

abuse, increasing the number of alcohol and drug workers, reducing Foetal Alcohol Spectrum

Disorders, reducing alcohol-related road traffic accidents, reducing community violence and

dysfunction, and supporting community chosen Alcohol Management Plans (Australian

Government 2013). Improved efforts to identify best evidence interventions for reducing

alcohol misuse among Indigenous Australians, and effective methods for tailoring them to the

specific circumstances of Indigenous communities would help to achieve the alcohol-related

aims of the Closing the Gap building blocks.

Improving intervention research

Systematic reviews of the published Indigenous health literature have identified a

predominance of descriptive research in the Indigenous health research field, and a need for

more Indigenous-specific intervention research (Sanson-Fisher et al. 2006; Gray et al. 2000).

Specifically, with respect to alcohol research there is a lack of intervention and measures

research, and the limited number of intervention evaluations that have been published tend to

focus on primary interventions (e.g. health promotion, alcohol restrictions) with little attention

to secondary interventions (e.g. brief interventions, cognitive-behavioural interventions) (Gray

et al. 2000; Clifford et al. 2010; Shakeshaft, Clifford & Shakeshaft 2010). The main

consequence of continuing the current trend in Indigenous alcohol research would be an

ongoing lack of reliable evidence for the types of interventions that are likely to be most cost-

effective for difference types of alcohol-related problems, and an increased likelihood that

interventions of unknown effectiveness and cost will continue to be implemented.

21

To adequately determine their cost-effectiveness, Indigenous-specific interventions require

careful consideration and development, comprising both meaningful consultation and

collaboration with Indigenous communities and rigorous evaluation using practical and

rigorous evaluation designs, and valid, reliable and acceptable measurement instruments

(Gray et al. 2000; Clifford et al. 2010). Rigorous evaluations that use valid and reliable

instruments to measure outcomes are required to determine the true effect of an intervention

(Sanson-Fisher & Campbell 1994). Indigenous-specific measures with published validity and

reliability are rare (Clifford et al. 2010; Shakeshaft, Clifford & Shakeshaft 2010) and, as such,

their development should be a priority for researchers.

Tailoring evidence-based interventions with potential to reduce alcohol-related harms to the

needs and preferences of Indigenous communities and health care services increases both the

likelihood that they will prove to be cost-effective and that those shown to be cost-effective

will be able to be integrated into routine care (Shakeshaft, Clifford & Shakeshaft 2010). Family-

based approaches have been shown to be effective for reducing alcohol-related harms in non-

Indigenous populations (Miller & Wilbourne 2002; Smit et al. 2008; Templeton, Velleman &

Russell 2010), and they are likely to be acceptable to Indigenous Australians for four main

reasons: 1) family members in close contact with problem drinkers are at risk of alcohol-

related violence, conflict, sexual assault, psychological abuse and/or neglect (Kelly &

Kowalyszyn 2003; Laslett et al. 2010); 2) positive family relationships are the foundation for

community cohesion in Indigenous communities (McLennan & Khavarpour 2004) and can

promote behavioural change (Nagel & Thompson 2010); 3) family-based approaches align with

the Indigenous Australian cultural practice of including family members in health care

communications (McGrath et al. 2006); and 4) family-based approaches are consistent with

the Indigenous Australian concept of health that incorporates physical, social, emotional, and

cultural wellbeing (Brady 2004).

22

Evidence-based interventions tailored for Indigenous Australians and delivered through

Indigenous-specific health care services improves the likelihood that they will be accessed by

Indigenous Australians, because they are more likely to seek culturally appropriate care

(Henry, Houston & Mooney 2004). Aboriginal Community Controlled Health Services (ACCHSs)

are primary care services aimed at providing high quality holistic and culturally appropriate

care through local Indigenous community planning and management. ACCHSs often provide

primary and secondary interventions aimed at addressing low and risky alcohol consumption

(Hunter et al. 2005). Tertiary interventions, addressing high-risk alcohol use and high levels of

alcohol dependence, are usually delivered to Indigenous Australians through drug and alcohol

treatment agencies (Brady, Dawe & Richmond 1998). Although drug and alcohol treatment

agencies are not always governed by Indigenous Australians, they can provide specialist care

through health care providers who have experience working with Indigenous Australians.

Irrespective of the specific nature of the health care service, the extent to which it is utilised by

Indigenous people, and their willingness to engage in research, is fundamentally determined

by the level of trust that exists between the health care service and the local Indigenous

community (Allan & Campbell 2011).

Working in partnership with Indigenous Australians and health care providers

The development of Indigenous-specific interventions for delivery through routine health care

services requires ongoing consultation with Indigenous people (Gray et al. 1995). This includes,

but is not limited to, a steering committee that comprises Indigenous Australian

representatives (Henderson et al. 2002). The process of consultation addresses Indigenous

people’s right to self-determination (United Nations 2008) and provides acknowledgment of,

and respect for, differences in cultural beliefs and systems between Indigenous and non-

Indigenous Australians, and the diversity of Indigenous peoples (Australian Institute of

23

Aboriginal and Torres Strait Islander Studies 2010; National Health and Medical Research

Council 2003). To optimise the feasibility and likely cost-effectiveness of Indigenous-specific

interventions, they must be acceptable to the needs and circumstances of Indigenous people

and to the health care providers who will deliver them to Indigenous people. The support of

health care providers for a proposed intervention is integral to the success with which it is

likely to be delivered in the context of routine care.

Historically evidence-based research has been developed in an academic setting without

consultation with health care providers or community members and presented to health care

providers for implementation into routine practice (Green 2008). This method has not been

successful in ensuring that evidence-based research is used in clinical practice settings,

because what works in a controlled environment under strict conditions, as is the case for

rigorously designed trials, is not always effective or appropriate in a real world setting

(Westfall, Mold & Fagnan 2007). The participation of health care providers and community

members in the development of locally targeted evidence-based interventions is more likely to

result in implementation into routine practice, than if research evidence is developed and

disseminated to health care services without consultation (Green 2008). The process of

consultation provides an opportunity for the perceived needs of health care providers and of

community members to be incorporated into research.

Translational research aims to achieve the balance between research informing practice and

practice and perceived needs informing research (Marincola 2003; Havard Catalyst 2013), and

has been categorised into five different types: T1) basic research into clinical effect; T2) clinical

effect into clinical intervention; T3) clinical intervention into clinical practice; T4) specific public

health intervention at a population level; and T5) clinical, public health and determinants-

related interventions applied to the population or specific sub-population (Thompson 2012).

24

Since T5 research is most relevant to intervention research that is integrated into the routine

delivery of health care services, its applicability to Indigenous Australians is most likely to be in

the context of health care services provided by ACCHSs, or provided by health care providers

who are employed by mainstream treatment agencies but have experience working with

Indigenous Australians (Brady, Dawe & Richmond 1998; Hunter et al. 2005). Researchers

working in consultation with health care providers who routinely interact with Indigenous

Australians, and with Indigenous Australians themselves, creates the opportunity for

Indigenous-specific research to inform practice and, conversely, for the requirements of

clinical practice and the perceived needs of Indigenous clients and communities, to inform

research. Factors that may limit the practical application of this dynamic model of integrated

clinical practice and evaluation include: limited clinician access to existing research findings

and evaluation expertise; no encouragement from the health care organisation for staff to

continue learning; the lack of incentive for researchers to engage with health care providers;

and a range of individual-level factors (e.g. personal beliefs, lack of motivation) (Barratt 2003).

One potential way to address these barriers is to develop formal partnerships between

researchers, health care providers and Indigenous Australians, that allow each of them to

contribute their own skills to identify best evidence interventions, tailor them to meet the

needs and fit the circumstances of relevant Indigenous communities, families and health care

providers, implement them in the context of routine service delivery and, ultimately, evaluate

their impact and costs. Given the historical nature of the relationship between Indigenous and

non-Indigenous Australians, these partnerships are most likely to be effective if they explicitly

foster Indigenous control of, or at a minimum meaningful Indigenous participation in, all

phases of their own health research.

25

This thesis aimed to demonstrate one such process of researchers working in partnership with

health care providers and Indigenous Australians in the context of routine provision of health

care services. The partnership identified and tailored promising interventions to reduce rates

of alcohol-related harm experienced by Indigenous Australians, and devised Indigenous-

specific reliable and valid measures of alcohol misuse and harm to identify at-risk individuals

and provide a psychometrically tested outcome measure. It also sought to respond to concerns

specifically raised by Indigenous participants about the particular negative impact of alcohol on

Indigenous young people. Following from this doctoral research, participants are being

recruited to take part in the tailored interventions and baseline and follow-up data is being

collected to assess their cost-effectiveness. The evaluation of the tailored interventions will

occur as part of the ongoing partnership that has been established by this doctoral research.

Overview of chapters

Paper 1 presents the results of a systematic review of family-based interventions aimed at

reducing alcohol-related harms. The review was limited to family-based interventions because

they are most consistent with the intervention approach that both the Indigenous community

and the health care providers involved in the partnership thought would be most acceptable in

their communities. The review identified 1,369 studies, of which 142 were classified as

intervention studies. Nineteen intervention studies were family-based alcohol interventions:

eleven included the family member in the treatment of the problem drinker; and eight

specifically targeted family members of problem drinkers. Community Reinforcement and

Family Training (CRAFT) was identified as an intervention approach that had at least some

evidence for its effectiveness and had potential to be successfully tailored for delivery to

Indigenous people. CRAFT is an intervention that targets family members of problem drinkers

and teaches them skills to support their problem drinking relative to reduce their alcohol

consumption by removing positive reinforcement for drinking behaviour. CRAFT also teaches

26

family members of problem drinkers how to increase their own social and emotional

wellbeing.

Paper 2 identifies Indigenous-specific cut-off scores for two short versions of the Alcohol Use

Disorders Identification Test (AUDIT), a measure of problematic alcohol use: AUDIT-C and

AUDIT-3. Indigenous-specific AUDIT-C and AUDIT-3 cut-off scores could be used to screen

Indigenous people for enrolment into interventions and to measure intervention outcomes.

Paper 3 presents health care providers’ suggestions for tailoring CRAFT and the Community

Reinforcement Approach (CRA) (an intervention that targets problem drinkers from which

CRAFT was modelled) for Indigenous Australians, and their perceptions of the CRA and CRAFT

certification process. Changes to technical language, fewer sessions and the availability of

group sessions were suggested. The certification process was viewed positively.

Paper 4 presents Indigenous Australians’ perceptions of, and suggestions for, tailoring CRA and

CRAFT for delivery in their local community. The interventions were viewed favourably. In

addition to reaffirming the communities’ commitment to trialling a family-based approach, a

perception that young Indigenous people were at particular risk of alcohol-related harm was

highlighted; an issue explored in papers 5 and 6.

Paper 5 investigates differences in experienced alcohol-related harm for Indigenous

Australians, compared to the general Australian population, by age and sex. The findings are

consistent with the perceptions of the participants in Paper 4 that young Indigenous people

generally experience a disproportionately high burden of alcohol-related harm, relative to the

general Australian population.

27

Paper 6 presents the results of a systematic review of the peer-reviewed literature on

intervention evaluations for young people at high risk of alcohol-related harm. The review

identified 1,697 studies, of which 148 were classified as intervention studies. Nine studies

evaluating interventions targeting young people at high risk of alcohol-related harm were

identified. This review identified that the interventions with the most potential to help reduce

alcohol-related harms among high risk young people were cognitive-behavioural therapy,

family therapy and CRA.

The final section of this thesis discusses the implications of the findings of Papers 1 to 6 and

presents avenues for future research, including proposed guiding principles for researchers

developing partnerships with health care providers and Indigenous Australians to help improve

the quality of Indigenous intervention research and, ultimately, the health of Indigenous

Australians.

28

Paper 1

A systematic review of family-based interventions targeting alcohol misuse

and their potential to reduce alcohol-related harm in Indigenous

communities

Bianca Calabria1, Anton Clifford2, Anthony P. Shakeshaft1, Christopher M. Doran3,4,5

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales,

Australia

2. Queensland Alcohol and Drug Research and Education Centre, School of Population Health, University

of Queensland, Brisbane, Queensland, Australia

3. Hunter Medical Research Centre, Newcastle, New South Wales, Australia

4. University of Newcastle, Newcastle, New South Wales, Australia

5. Hunter Valley Research Foundation, Newcastle, New South Wales, Australia

Paper 1 has been published in the Journal of Studies on Alcohol and Drugs (Calabria et al. 2012).

29

Copyright Statement

I certify that this publication was a direct result of my research towards this PhD, and that

reproduction in this thesis does not breach copyright regulations.

Calabria, B, Clifford, A, Shakeshaft, A & Doran, C 2012, 'Systematic review of family-based

interventions targeting alcohol misuse and their potential to reduce alcohol-related harm in

Indigenous communities', Journal of Studies on Alcohol and Drugs, vol. 73, no. 3, pp. 477-488.


30

Preamble

Paper 1 systematically reviews the peer-review literature to identify the family-based approaches

for reducing alcohol-related harm that have the most potential to be tailored for delivery to

Indigenous people. An initial systematic search of the peer-reviewed literature, using the same

methodology described in this paper, was undertaken to identify published evaluations of family-

based alcohol interventions specifically targeting Indigenous Australians; however, this search

identified no relevant studies. When evidence about intervention effectiveness that has been

established specifically in Indigenous health care settings is not available, it may be possible to

tailor interventions that have been evaluated in non-Indigenous health care settings to Indigenous

settings, provided there is little likelihood of harmful outcomes for participants (Shakeshaft,

Clifford & Shakeshaft 2010). A broader systematic search of the peer-review literature was

therefore undertaken to identify published evaluations of family-based alcohol interventions

targeting any population group. The acceptability and feasibility to health care providers and

Indigenous Australians of the most promising interventions would subsequently be explored.

Although the findings of this systematic review are applicable to both Indigenous and non-

Indigenous populations, the main purpose of the review is to identify which family-based

interventions appear most promising to reduce alcohol-related harm in Indigenous communities.

31

Abstract

Objective: Alcohol misuse is a major risk factor for harm in Indigenous communities. The

Indigenous family unit is often the setting for, and is most adversely affected by, alcohol-related

harm. Therefore, family-based alcohol interventions offer great potential to reduce alcohol-related

harm in Indigenous communities. This systematic review aims to identify peer-reviewed

publications of evaluations of family-based alcohol interventions, critique the methodological

quality of those studies and describe their intervention characteristics, and identify which

interventions appear most promising to reduce alcohol-related harm in Indigenous communities.

Method: Eleven electronic databases were searched. The reference lists of reviews of family-based

approaches focused on alcohol interventions were hand-searched for additional relevant studies

not identified by the electronic database search.

Results: Initially, 1,369 studies were identified, of which 21% (n = 142) were classified as

intervention studies. Nineteen intervention studies were family-based alcohol interventions.

Eleven of these studies included family members in the treatment of problem drinkers, and eight

studies specifically targeted family members of problem drinkers. Methodological quality of

studies varied, particularly in relation to study design, including confounding variables in the

analyses, and follow-up rates.

Conclusions: The evidence for the effectiveness of family-based alcohol interventions is less than

optimal, although the reviewed studies did show improved outcomes. Given the important role of

family in Indigenous communities, there is merit in exploring family-based approaches to reduce

alcohol-related harms. Tailored family-based approaches should be developed with direct

consultation with targeted Indigenous communities.

32

Introduction

Indigenous peoples have a historical continuity with pre-colonial traditional societies. They derive

a sense of identify from, and have a strong connection to, their traditional lands. Indigenous

peoples communicate their strong understanding of and connection with their past through varied

and distinct lifestyle and cultural practices. Adaptations away from traditional land, lifestyle and

culture do not negate Indigenous identity (Coates 2004).

In countries where alcohol use is culturally acceptable, a greater proportion of Indigenous people

abstain from alcohol use compared to the general population; however, among those that do

drink, Indigenous people consume alcohol at riskier levels (Australian Department of Human

Services and Health 1995; First Nations/First Nationals Information Governance Committee 2007;

Bramley et al. 2003). In other countries, where alcohol is only consumed by a minority of the

population, Indigenous people are more likely to consume alcohol than those in the general

population (Subramanian, Smith & Subramanyam 2006). As a result, Indigenous people experience

a disproportionately high burden of alcohol-related harm compared with the general population

(Centre for Disease Control 2008; Calabria et al. 2010). Alcohol-related mortality rates are

between two (Centre for Disease Control 2008; Connor et al. 2004) and eight (Vos et al. 2003;

Begg et al. 2007) times higher among Indigenous populations compared to the general population.

The main contributors to alcohol-related mortality among Indigenous people are homicide and

violence, injury, suicide (including self-inflicted injury), and road traffic accidents (Centre for

Disease Control 2008; Vos et al. 2003; Connor et al. 2004; Calabria et al. 2010; Begg et al. 2007).

Despite these extraordinarily high rates of alcohol-related harm, Indigenous peoples’ access to

health services and programs to reduce these harms is disproportionately low (Berry & Crowe

33

2009; KnowledgeAssets 2009). Mainstream services and programs are generally unacceptable

and/or inappropriate for Indigenous peoples (Dodgson & Struthers 2005; Hayman, White &

Spurling 2009), and Indigenous-specific alcohol services are often lacking and/or inadequately

resourced (Gray et al. 2010; Allison, Rivers & Fottler 2004). As a consequence, Indigenous peoples

require improved access to acceptable and appropriate alcohol intervention services and

programs.

The harms resulting from alcohol misuse extend beyond drinkers to their families and

communities. Family members and friends who have regular contact with a problem drinker are at

increased risk of alcohol-related violence, conflict, sexual assault, psychological abuse, and/or

neglect (Laslett et al. 2010; Kelly & Kowalyszyn 2003; Seale et al. 2002). These negative personal

relationships can result in psychological distress (Laslett et al. 2010; Seale et al. 2002). Conversely,

positive family relationships are the foundation for community cohesion among Indigenous groups

(McLennan & Khavarpour 2004) and can promote behavioural change (Nagel & Thompson 2010).

Given the increased risk of alcohol-related harm among relatives of problem drinkers and the

central role that family relationships play in Indigenous communities, family member participation

in interventions to help problem drinkers reduce their alcohol consumption is likely to result in

better outcomes than interventions that target problem drinkers only.

Family-based interventions have proven to be effective in non-Indigenous populations

(Templeton, Velleman & Russell 2010; Smit et al. 2008; Miller & Wilbourne 2002). Cultural

adaptation of evidence-based interventions to increase their likelihood of proving acceptable and

effective for Indigenous people is, however, necessary and appropriate because of differences in

their cultural values, knowledge bases and levels of exposure to risk factors (Bernal, Jimeńez-

34

Chafey & Rodreguez 2009; Lau 2006). Despite calls for increased family support services for

Indigenous communities (Gray et al. 2010; Seale et al. 2006), the effectiveness and

appropriateness of family-based interventions for reducing alcohol-related harm in Indigenous

communities is yet to be rigorously examined.

The aims of this paper are threefold: first, to identify peer-reviewed publications of evaluations of

family-based alcohol interventions; second, to critique the methodological quality of those studies

and describe their intervention characteristics; and third, to identify which interventions appear

most promising to reduce alcohol-related harm in Indigenous communities.

Method

Sample

The search was limited to publications dated 2003-2010 (inclusive) to complement, rather than

replicate, a previous review of family-based interventions, published in 2005 (Copello, Velleman &

Templeton 2005).

Search strategy

Figure 1 summarises the databases searched, the search terms used, the exclusion criteria, and

classification of included studies (see Appendix A for search strings).

35

Database search: EMBASE, ERIC, Family studies abstracts, Indigenous Australian Alcohol and Other Drugs Bibliographic

Database, Indigenous HealthInfoNet, Medline, Project Cork, Proquest Social Science Journals, PsycINFO, Sociological

Abstracts, and Web of Science.

Separate search for each database using database specific search strings:

Keywords used: alcohol, intervention/family intervention. Family

Limited (when possible) to: 2003-2010, peer-reviewed/scholarly articles, human subject, English language

Total of 1362 citations/abstracts identified by the electronic database search (after deletion of duplicates).

Manual search of 1369 citations/abstracts

701 articles categorised by type of publication

Measurement

14 (2%)

Descriptive

408 (58%)

Intervention

142 (21%)

Dissemination/

adoption studies

9 (1%)

Reviews/ Not

raw data

128 (18%)

EXCLUDED

No alcohol focus, predictor or outcome 249

No family focus, predictor or outcome 230

Not peer reviewed 176

Not 2003-2010 10

Animal study 3

Total 668

EXCLUDED

Not alcohol intervention 20

Not family-based intervention 42

Prevention 51

Not English 1

Duplicate of family-based interventions 6

Not evaluation of intervention effectiveness 3

Total 123

Family-based interventions aimed at reducing

alcohol-related harm:

For a family member 8 With a family member 11 Total 19

Additional articles from hand

search of reference lists

7

Figure 1. Flowchart indicating search strategy and classification of articles

36

Consistent with methods detailed in the Cochrane Collaboration’s Handbook on Systematic

Reviews of Health Promotion and Public Health Interventions (Jackson 2007) and with previous

reviews (Havard, Shakeshaft & Sanson-Fisher 2008; Webb et al. 2009; Wood et al. 2006; Calabria,

Shakeshaft & Havard 2011; Shakeshaft, Bowman & Sanson-Fisher 1997), the search strategy

comprised two steps. First, consultation with a qualified archivist identified nine relevant

electronic databases to search: Project Cork, EMBASE, ERIC, Family Studies Abstract, MEDLINE,

Proquest Social Science Journals, PsycINFO, Sociological Abstracts, and Web of Science. Electronic

databases were searched individually with specific search strings as this search method is more

effective at identifying relevant articles than a simultaneous search using generic search terms

(Jackson 2007). The search terms (modelled from a previous review (Calabria, Shakeshaft &

Havard 2011)) “alcohol”, “family” and “intervention” were integrated into database specific search

strings. The combined searches of the nine databases located 3,032 references that were

imported into Endnote. An Endnote search for “intervention” was conducted to identify a

manageable number of citations for review. The Endnote search identified 1,250 articles for

classification. To maximise coverage of Indigenous-specific studies, the Indigenous Australian

Alcohol and Other Drugs Bibliographic Database (National Drug Research Institute) and the

Indigenous HealthInfoNet (Australian Government Department of Health and Ageing) were

searched using the same search terms. A total of 112 studies were identified for classification.

These were reviewed by hardcopy printouts because the databases lack the capacity to export

references to Endnote.

Second, reference lists of reviews of family-based approaches targeting alcohol (n = 44), identified

by Step 1, were hand-searched for relevant studies not yet identified. This process identified seven

37

relevant studies (Dutcher et al. 2009; Howells & Orford 2006; Latimer et al. 2003; Rychtarik &

McGillicuddy 2005; Walitzer & Dermen 2004; Doyle et al. 2003; Fals-Stewart et al. 2005).

Classification of studies

The abstracts of the 1,369 identified references were classified in a three-step process.

Step 1: Identification of studies for exclusion. Articles were excluded if: (a) they did not focus on

alcohol or if the outcome or predictor variables did not include alcohol (n = 249); (b) the subject of

the research was not defined as a family member (e.g. parent, spouse, sibling, or child) or the

outcome or predictor variables did not include family (e.g. family functioning or heritability)

(n = 230); (c) they were not peer-reviewed (n = 176); (d) they were not conducted in 2003-2010

(n = 10); or (e) they were animal studies (n = 3). Step 1 excluded 668 articles.

Step 2: Classification of studies. The remaining studies (n = 701) were classified as either

intervention studies or one of four other criteria derived and adapted from previous similar

reviews (Havard, Shakeshaft & Sanson-Fisher 2008; Webb et al. 2009; Wood et al. 2006; Calabria,

Shakeshaft & Havard 2011): (a) interventions, defined as evaluations or trials of family-based

intervention approaches designed to reduce alcohol-related harm, or evaluations or trials of

intervention approaches that include alcohol or family as an outcome or predictor variable

(n = 142); (b) measurement, defined as articles concerned primarily with developing measurement

instruments and/or testing the psychometric properties of measurement instruments (n = 14); (c)

descriptive, defined as data-based descriptive, analytical research on alcohol-related harm and

families (n = 408); (d) dissemination/adoption and acceptability/feasibility, defined as studies

evaluating approaches for improving the uptake and delivery of alcohol interventions by health

38

care practitioners, and/or the acceptability and/or feasibility of alcohol intervention delivery

(n = 9); and (e) reviews, defined as literature reviews, non-data-based articles and comments

(n = 128). Step 2 excluded 559 articles. Ten percent (n = 71) of classified articles were re-classified

by a blinded co-author (A.C.) to crosscheck classifications performed by the first author (B.C.). The

articles excluded in Step 1 were not cross-checked because they were not relevant for the review.

Agreement between co-authors was approaching substantial ( = 0.58). Discrepancies were

discussed and resolved. Sufficient agreement between co-authors deemed crosschecking more

than 10% of article classifications unnecessary.

Step 3: Identification of family-based alcohol intervention studies. Of the 142 intervention papers

identified, 123 were excluded for the following reasons: (a) they were not an alcohol intervention

(n = 20), (b) they were not a family-based alcohol intervention (n = 42), (c) they were preventive

interventions (n = 51), (d) they were not published in English (n = 1), (e) they were duplicate

articles based on intervention studies already included (n = 6), or (f) they did not report on the

effectiveness of an intervention (e.g. compared outcomes of ethnic groups participating in the

intervention) (n = 3). Step 3 excluded 123 articles and identified 19 family-based intervention

studies for critical review.

Data extraction from studies

Criteria for data extraction from studies were adapted from the Cochrane Collaboration’s

Handbook for Systematic Reviews of Health Promotion and Public Health Interventions (Jackson

2007). The criteria relate to the intervention/s sample (including eligibility, size, age range, and

percent male), outcomes measured, and cost calculations performed.

39

Methodological critique of intervention studies

Methodological quality was assessed using the Dictionary for the Effective Public Health Practice

Project Quality Assessment Tool for Quantitative Studies (Jackson 2007). Sections A to F (A =

selection bias; B = allocation bias; C = confounders; D = blinding; E = data collection methods; and

F = withdrawal and drop-outs) were coded weak, moderate, or strong, consistent with the

component rating scale of the Dictionary (Jackson 2007). For Sections G (analysis) and H

(intervention integrity) descriptive information was recorded, using dictionary recommendations

as a guide.

Results

Intervention type and setting

All family-based interventions identified were counselling-based interventions: 11 targeted

problem drinkers and their family members, and 8 targeted family members of problem drinkers

only (Table 1). The delivery mode for interventions targeting problem drinkers and their family

members included individual sessions (Boyd-Ball 2003; Liddle et al. 2009; Nattala et al. 2010;

O'Farrell et al. 2008; Slesnick & Prestopnik 2009; Vedel, Emmelkamp & Schippers 2008), individual

sessions with concurrent group and/or family/couples sessions (Doyle et al. 2003; Esposito-

Smythers et al. 2006; Fals-Stewart et al. 2005; Slesnick & Prestopnik 2009), group sessions with

concurrent family/couples sessions (Doyle et al. 2003; Latimer et al. 2003), family/couples sessions

(Fals-Stewart et al. 2005; Nattala et al. 2010; Slesnick & Prestopnik 2009; Vedel, Emmelkamp &

Schippers 2008), or group sessions (Walitzer & Dermen 2004; Fals-Stewart et al. 2005; Latimer et

al. 2003; Liddle et al. 2009). Interventions targeting problem drinkers and their family members

were delivered in tertiary health care settings (Boyd-Ball 2003; Doyle et al. 2003; Esposito-

40

Smythers et al. 2006; Fals-Stewart et al. 2005; Latimer et al. 2003; Liddle et al. 2009; Nattala et al.

2010; O'Farrell et al. 2008; Vedel, Emmelkamp & Schippers 2008); a research centre (Walitzer &

Dermen 2004); and within a home, an office or runaway shelter (Slesnick & Prestopnik 2009). The

delivery mode for interventions targeting family members of problem drinkers included individual

sessions (Copello et al. 2009; Dutcher et al. 2009; Hansson et al. 2006; Hansson et al. 2004;

Howells & Orford 2006; Landau et al. 2004), group sessions (de los Angeles Cruz-Almanza, Gaona-

Marquez & Sanchez-Sosa 2006; Hansson et al. 2004; Rychtarik & McGillicuddy 2005), or a

combination of both (Rychtarik & McGillicuddy 2005). Interventions targeting family members of

problem drinkers were delivered in primary health care settings (de los Angeles Cruz-Almanza,

Gaona-Marquez & Sanchez-Sosa 2006; Copello et al. 2009), tertiary health care settings (Dutcher

et al. 2009; Howells & Orford 2006; Landau et al. 2004), and a university (Hansson et al. 2006).

41

Table 1. Family-based interventions for problem drinkers and/or their family members

Reference Intervention/s

(number of sessions)

Design Sample (n) Effect Follow-up

months

Boyd-Ball

(2003)

“The Shadow Project”

Parenting training + relationship

training (1)

Quasi-

experimental

Youth entering alcohol

and drug inpatient

treatment and their family

member

(n = 66)

Increase in % days abstinent from alcohol,

marijuana, and "other hard drugs"

11

Copello

(2009)

Based on stress-strain-coping

model of addition and family

a) Full intervention (5)

b) Brief intervention (1)

RCT Family members of

problem drinkers/problem

drug users

(n = 143)

No significant difference between the two

interventions

2

de los

Angeles

Cruz-

Almanza

(2006)

Rational-emotive behavioral

therapy (18)

Multiple

baseline across

two groups

Spouses of problem

drinkers

(n = 18)

Improvements in self-esteem, coping, and

likelihood of behaving assertively for intervention

group

18

Doyle

(2003)

a) Residential program (6-week

program)

b) Community program (10-week

program)

Pre and post Problem drinkers from a

residential treatment

centre and the community

and their family member

(n = 67)

The residential group:Increase in number of

abstinent participants, decrease in negative

consequences and psychological adjustment

The community group: Increase in number of

moderate drinkers

6

Dutcher

(2009)

Community Reinforcement and

Family Training (12)

Demonstration

trial

Family members of

problem drinkers

(n = 98)

55% overall engagement

Decrease in family member’s depression, state

anger (but not trait ander), state and trait

anxiety. Increase in relationship happiness

12

42




months

Esposito-

Smythers

(2006)

Cognitive behavioral treatment

protocol + conjoint family sessions

(35)

Case study Youth with co-occuring

alcohol use disorder and

suicidality and their

parent/s

(n = 6)

Decrease in suicidality, marijuana and alcohol use 12

Fals-

Stewart

(2005)

a) Brief relationship therapy (18)

b) Shortened version of standard

behavioral couples therapy

(24)

c) Individual-based treatment

(18)

d) Psychoeducational attention

control treatment (18)

RCT Entering outpatient

treatment and their

spouse

(n = 100)

Shortened version of behavioral couples therapy

had equivalent heavy drinking outcomes to brief

relationship therapy

Heavy drinking and dyadic adjustment outcomes

for brief relationship therapy were superior to

patients in the other individual-based treatment

and psychoeducational attention control

treatment

12

Hansson

(2004)

a) Individual standard

information session (1)

b) Individual coping skills training

(1)

c) Group support (12)

RCT Spouses of problem

drinkers

(n = 39)

Increase in coping behaviour, psychiatric

symptoms, and hardship, but no difference

between groups

24

Hansson

(2006)

a) Alcohol intervention program

(2)

b) Coping intervention program

(2)

c) Combination program (2)

RCT Children of problem

drinkers

(n = 82)

Alcohol interventions improved drinking pattern

compared to the coping intervention group

12

Howells

(2006)

Standardised counselling program

(average of 4)

Pre and post Partners of problem

drinkers

(n = 56)

Decrease in stress level and coping for

intervention group

12

43




months

Landau

(2004)

A Relational Sequence for

Engagement (ARISE) (9)

Demonstration

trial

Family member/friend of

problem drinker/problem

drug user

(n = 110)

83% of problem drinker/probelm drug user

engaged in treatment/self-help

0

Latimer

(2003)

a) Integrated family and cognitive

behavioral therapy (48)

b) Drugs harm psychoeducation

curriculum (16)

RCT Youth with psychocative

substance use disorders

and their partent/s

(n = 43)

Family therapy group: youth decrease in alcohol

use, marijuana use, and problem avoidance

Increase in rational problem solving and learning

strateggy skills

Parents more adaptive scores on

communication, involvement, control, and

values/norms indicides

6

Liddle

(2009)

a) Multidimensional family

therapy (24-32)

b) Cognitive behavioral peer

group intervention (24-32)

RCT Youth referred for a

substance use problem

and their parent/s

(n = 83)

Multidimensional family therapy: decrease in

substance use, delinquency, internalised distress,

affiliation with deliquent peers

Increase in family and school functioning

12

Nattala

(2010)

a) Individual relapse prevention

(8-10)

b) Dyadic relapse prevention (8-

10)

c) Treatment as usual

RCT Admitted to an inpatient

facility and their family

member

(n = 87)

Dyadic replase prevention had better outcomes

than individual relapse prevention and treatment

as usual

6

O'Farrell

(2008)

a) Brief family treatment (2)

b) Treatment as usual

RCT Admitted to a detox unit

and their parent/s, wife,

or female partner

(n = 45)

Family treatment: patients were more likely to

enter continuing care

Alcohol and drug use decreased for patients who

entered continuing care regardless of treatment

3

Rychtarik

(2005)

a) Coping skills training (8)

b) 12-step facilitation (8)

c) Delayed treatment

RCT Spouses of problem

drinkers

(n = 171)

Interventions decreased depression levels but did

not differ from each other. Interventions

decreased partner drinking

12

44




months

Slesnick

(2009)

a) Home-based ecological family

therapy (16)

b) Office-based functional family

therapy (16)

c) Treatment as usual

RCT Primary alcohol problem

runaway youth and their

primary caretaker/s

(n = 119)

Home-based family therapy: decreased alcohol

use for adolescents

Office-based family therapy: decreased alcohol

use for adolescents

15

Vedel

(2008)

a) Behavioral couples therapy

(10)

b) Cognitive behavioral therapy

(10)

RCT Patients and their spouse

(n = 64)

Couples therapy and cognitive-behavioral

therapy were both effective in changing drinking

behavior

Marital satisfaction of the spouse increased in

the couples therapy

Self-efficacy to withstand alcohol-related high-

risk situations increased more in cognitive

behavioral therapy than in couples therapy

6

Walitzer

(2004)

a) Treatment for problem

drinkers only (10)

b) Couples alcohol treatment (10)

c) Couples alcohol treatment and

behavioral couples therapy

(10)

RCT Drinkers (≥10 drinks per

week) and their female

spouse

(n = 64)

Couples treatmemt: decrease in alcohol

consumption

The additional of behavioral couples therapy to

couples alcohol treatment did not significantly

improve outcomes

12

Note. RCT = Randomised control/clinical trial.

45

Sample population targeted by interventions

One intervention specifically targeted an Indigenous population: Native Americans (Boyd-Ball

2003). Across interventions for problem drinkers and their family members, problem drinking

youth (Boyd-Ball 2003; Esposito-Smythers et al. 2006; Latimer et al. 2003; Liddle et al. 2009;

Slesnick & Prestopnik 2009) or adults (Doyle et al. 2003; Fals-Stewart et al. 2005; Nattala et al.

2010; O'Farrell et al. 2008; Vedel, Emmelkamp & Schippers 2008; Walitzer & Dermen 2004) were

targeted. Types of family members targeted in the treatment of problem drinkers included parents

(Esposito-Smythers et al. 2006; Latimer et al. 2003; Liddle et al. 2009) or other family members

(Boyd-Ball 2003; Slesnick & Prestopnik 2009) for adolescent problem drinkers, and spouse (Fals-

Stewart et al. 2005; Vedel, Emmelkamp & Schippers 2008; Walitzer & Dermen 2004) or other

family members (Doyle et al. 2003; Nattala et al. 2010; O'Farrell et al. 2008) for adult problem

drinkers. Interventions for family members only targeted a spouse (de los Angeles Cruz-Almanza,

Gaona-Marquez & Sanchez-Sosa 2006; Hansson et al. 2004; Howells & Orford 2006; Rychtarik &

McGillicuddy 2005) or other family members (Dutcher et al. 2009; Landau et al. 2004; Copello et

al. 2009; Hansson et al. 2006) of a problem drinker. Samples ranged in age from 12 to 78 years.

The percentage range of male participants was 17% (Esposito-Smythers et al. 2006) to 100% (Fals-

Stewart et al. 2005; Nattala et al. 2010; Walitzer & Dermen 2004) for interventions targeting

problem drinkers and 0% (de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006) to

31% (Landau et al. 2004) for interventions targeting family members.

Eligibility criteria

Alcohol use/dependence eligibility criteria for problem drinkers whose family members were

involved in their treatment varied across studies and were treatment samples (Boyd-Ball 2003;

Doyle et al. 2003; Liddle et al. 2009), alcohol dependence/abuse diagnosis (Fals-Stewart et al.

46

2005; Latimer et al. 2003; Vedel, Emmelkamp & Schippers 2008; Nattala et al. 2010; Esposito-

Smythers et al. 2006; O'Farrell et al. 2008), or problem alcohol use (Slesnick & Prestopnik 2009;

Walitzer & Dermen 2004).

Eligibility criteria for family members of problem drinkers were the family member’s perception

that their relative had a drinking problem defined by the family member’s reports of problematic

patterns of alcohol consumption (Dutcher et al. 2009; Hansson et al. 2004; Hansson et al. 2006;

Howells & Orford 2006; Landau et al. 2004; Rychtarik & McGillicuddy 2005) or the family

member’s perceptions of the impact of the problem drinker’s negative behaviour on their

wellbeing (Copello et al. 2009; de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa

2006).

Data collection methods

Self-report and non-self-report measures. All 19 studies used self-report measures. Eight studies

conducted interviews (Hansson et al. 2006; Hansson et al. 2004; Rychtarik & McGillicuddy 2005;

Doyle et al. 2003; Fals-Stewart et al. 2005; Latimer et al. 2003; Walitzer & Dermen 2004; Vedel,

Emmelkamp & Schippers 2008), and five used corroborated reports (Rychtarik & McGillicuddy

2005; Fals-Stewart et al. 2005; Latimer et al. 2003; Nattala et al. 2010; Walitzer & Dermen 2004).

In six studies, non-self-report measures were also used: Two used urine tests (Latimer et al. 2003;

Slesnick & Prestopnik 2009), two used observational methods (Liddle et al. 2009; Boyd-Ball 2003),

and two checked medical records (Landau et al. 2004; O'Farrell et al. 2008).

Measurement instruments for alcohol use and/or dependence. Ten of the eleven studies targeting

problem drinkers and their family members measured alcohol use and/or dependence with a

47

validated instrument. Instruments were Timeline Follow-back Interview (O'Farrell et al. 2008;

Liddle et al. 2009; Doyle et al. 2003; Esposito-Smythers et al. 2006; Fals-Stewart et al. 2005), the

Alcohol Dependence Scale (Doyle et al. 2003; Walitzer & Dermen 2004), Structured Clinical

Interview for DSM-IV (Vedel, Emmelkamp & Schippers 2008; Fals-Stewart et al. 2005), Diagnostic

Interview of Children and Adolescents (Latimer et al. 2003), the Adolescent Diagnostic Interview-

Revised (Latimer et al. 2003), the Personal Experience Inventory (Latimer et al. 2003), the Problem

Oriented Screening Instrument for Teenagers (Liddle et al. 2009), Form 90 (Nattala et al. 2010;

Slesnick & Prestopnik 2009), and the Alcohol Use Disorders Identification Test (AUDIT) (Vedel,

Emmelkamp & Schippers 2008). Two studies also used quantity and frequency questions (Vedel,

Emmelkamp & Schippers 2008; Walitzer & Dermen 2004).

Two of the eight studies targeting only family members of problem drinkers measured their

alcohol consumption using the following validated instruments: the AUDIT (Hansson et al. 2004;

Hansson et al. 2006) and the Estimated Blood Alcohol Concentration Method (Hansson et al.

2006).

Outcome measures. The most frequently measured outcome for problem drinkers was alcohol

consumption (Boyd-Ball 2003; Doyle et al. 2003; Esposito-Smythers et al. 2006; Fals-Stewart et al.

2005; Latimer et al. 2003; Liddle et al. 2009; Nattala et al. 2010; O'Farrell et al. 2008; Slesnick &

Prestopnik 2009; Vedel, Emmelkamp & Schippers 2008; Walitzer & Dermen 2004), followed by

illicit drug use (Boyd-Ball 2003; Esposito-Smythers et al. 2006; Fals-Stewart et al. 2005; Latimer et

al. 2003; Liddle et al. 2009; O'Farrell et al. 2008; Slesnick & Prestopnik 2009). Primary outcomes

recurrently measured for family members of problems drinkers were coping (Howells & Orford

2006; Hansson et al. 2006; Hansson et al. 2004; de los Angeles Cruz-Almanza, Gaona-Marquez &

48

Sanchez-Sosa 2006; Copello et al. 2009), self-esteem (Howells & Orford 2006; Copello et al. 2009;

de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006), and engagement in

treatment service and/or help seeking (Howells & Orford 2006; Dutcher et al. 2009; Landau et al.

2004; Rychtarik & McGillicuddy 2005).

Family/marital functioning/satisfaction/cohesion was measured by eight studies (Doyle et al.

2003; Latimer et al. 2003; Liddle et al. 2009; Nattala et al. 2010; Slesnick & Prestopnik 2009; Vedel,

Emmelkamp & Schippers 2008; Walitzer & Dermen 2004; Rychtarik & McGillicuddy 2005). Eleven

studies were conducted in the United States (Dutcher et al. 2009; Landau et al. 2004; Rychtarik &

McGillicuddy 2005; Boyd-Ball 2003; Esposito-Smythers et al. 2006; Fals-Stewart et al. 2005;

Latimer et al. 2003; Liddle et al. 2009; O'Farrell et al. 2008; Slesnick & Prestopnik 2009; Walitzer &

Dermen 2004), three in the United Kingdom (Copello et al. 2009; Howells & Orford 2006; Doyle et

al. 2003), one in Mexico (de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006),

three in Europe (Sweden and Holland) (Hansson et al. 2006; Hansson et al. 2004; Vedel,

Emmelkamp & Schippers 2008), and one in India (Nattala et al. 2010).

Methodological Adequacy

Table 2 summarizes the methodological adequacy of the 19 studies. Two studies minimized

selection bias by identifying a representative sample and obtaining a high consent rate (Dutcher et

al. 2009; Liddle et al. 2009). Sixty-three percent of studies utilised a randomized control/clinical

trial, thereby reducing the risk of allocation bias (Copello et al. 2009; Hansson et al. 2006; Hansson

et al. 2004; Rychtarik & McGillicuddy 2005; Fals-Stewart et al. 2005; Latimer et al. 2003; Liddle et

al. 2009; Nattala et al. 2010; O'Farrell et al. 2008; Slesnick & Prestopnik 2009; Vedel, Emmelkamp

& Schippers 2008; Walitzer & Dermen 2004). Three quarters of the studies that reported

49

differences between groups did not control for these baseline variations, making it difficult to

ascertain whether post-test differences were attributed to the intervention (Hansson et al. 2006;

Hansson et al. 2004; Esposito-Smythers et al. 2006; Fals-Stewart et al. 2005; Nattala et al. 2010;

Slesnick & Prestopnik 2009).

Twelve studies allocated participants evenly across groups (de los Angeles Cruz-Almanza, Gaona-

Marquez & Sanchez-Sosa 2006; Hansson et al. 2006; Hansson et al. 2004; Rychtarik & McGillicuddy

2005; Fals-Stewart et al. 2005; Latimer et al. 2003; Liddle et al. 2009; Nattala et al. 2010; O'Farrell

et al. 2008; Slesnick & Prestopnik 2009; Vedel, Emmelkamp & Schippers 2008; Walitzer & Dermen

2004). Outcome assessors were blinded in one third of the applicable studies (Copello et al. 2009;

Hansson et al. 2006; Hansson et al. 2004; Rychtarik & McGillicuddy 2005; Vedel, Emmelkamp &

Schippers 2008). Measures with established psychometric properties were used by 84% of studies

(Copello et al. 2009; de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006; Dutcher

et al. 2009; Hansson et al. 2006; Hansson et al. 2004; Howells & Orford 2006; Rychtarik &

McGillicuddy 2005; Doyle et al. 2003; Fals-Stewart et al. 2005; Latimer et al. 2003; Liddle et al.

2009; Nattala et al. 2010; O'Farrell et al. 2008; Slesnick & Prestopnik 2009; Vedel, Emmelkamp &

Schippers 2008; Walitzer & Dermen 2004). Eight studies reported follow-up rates between 80%

and 100% (Copello et al. 2009; Hansson et al. 2006; Hansson et al. 2004; Boyd-Ball 2003; Esposito-

Smythers et al. 2006; Latimer et al. 2003; Nattala et al. 2010; O'Farrell et al. 2008).

50

Table 2. Methodological adequacy

Reference Selection bias (A) Allocation bias (B) Confounders (C) Blinding (D) Data collection

methods (E)

Withdrawal &

drop-outs (F)

Boyd-Ball (2003) Moderate Moderate Weak N/A Weak Strong

Copello (2009) Moderate Strong Strong Strong Strong Strong

de los Angeles Cruz-Almanza (2006) Weak Weak Weak Weak Strong Weak

Doyle (2003) Weak Weak N/A Weak Strong Weak

Dutcher (2009) Strong Weak N/A Weak Strong Weak

Esposito-Smythers (2006) Weak Weak Weak N/A Weak Strong

Fals-Stewart (2005) Weak Strong Weak Weak Strong Weak

Hansson (2004) Moderate Strong Weak Strong Strong Stong

Hansson (2006) Moderate Strong Weak Strong Strong Strong

Howells (2006) Moderate Weak Weak Weak Strong Weak

Landau (2004) Weak Weak N/A Weak Weak Weak

Latimer (2003) Moderate Strong Moderate Weak Strong Strong

Liddle (2009) Strong Strong Weak Weak Strong Weak

Nattala (2010) Weak Strong Weak Weak Stong Strong

O'Farrell (2008) Moderate Strong Moderate N/A Strong Strong

Rychtarik (2005) Weak Strong Moderate Strong Strong Moderate

Slesnick (2009) Moderate Strong Weak N/A Strong Weak

Vedel (2008) Weak Strong Strong Strong Strong Moderate

Walitzer (2004) Weak Strong Weak Weak Strong Moderate

Note. Measured by the Dictionary for the Effective Public Health Practice Project Quality Assessment tool for Quantitative Studies (see (Jackson 2007)).

Information on Analysis (G) and Intervention Integrity (H) is contained in the text of the paper. N/A = not applicable.

51

Three studies justified the appropriateness of their analyses by referencing a source for their

statistical approach (Copello et al. 2009; de los Angeles Cruz-Almanza, Gaona-Marquez &

Sanchez-Sosa 2006; Liddle et al. 2009). Follow-up rates varied from 9% (Vedel, Emmelkamp &

Schippers 2008) to 98% (Latimer et al. 2003; O'Farrell et al. 2008; Slesnick & Prestopnik 2009),

and intent-to-treat analyses were reported by one third of studies (Copello et al. 2009;

Rychtarik & McGillicuddy 2005; Latimer et al. 2003; Liddle et al. 2009; O'Farrell et al. 2008;

Slesnick & Prestopnik 2009; Walitzer & Dermen 2004).

Methods to optimise intervention fidelity were not reported by two studies (Hansson et al.

2004; Boyd-Ball 2003). When reported, most commonly reported methods to optimise

intervention fidelity were therapist training (Walitzer & Dermen 2004; Vedel, Emmelkamp &

Schippers 2008; Slesnick & Prestopnik 2009; Nattala et al. 2010; Latimer et al. 2003; Doyle et

al. 2003; Rychtarik & McGillicuddy 2005; Landau et al. 2004; Howells & Orford 2006; de los

Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006; Copello et al. 2009; Dutcher et

al. 2009; Hansson et al. 2006), therapist supervision (Walitzer & Dermen 2004; Vedel,

Emmelkamp & Schippers 2008; Slesnick & Prestopnik 2009; O'Farrell et al. 2008; Nattala et al.

2010; Latimer et al. 2003; Rychtarik & McGillicuddy 2005; Landau et al. 2004; Howells & Orford

2006; Copello et al. 2009), and intervention manuals/protocol (Walitzer & Dermen 2004;

Vedel, Emmelkamp & Schippers 2008; O'Farrell et al. 2008; Fals-Stewart et al. 2005; Esposito-

Smythers et al. 2006; Rychtarik & McGillicuddy 2005; Landau et al. 2004; Hansson et al. 2006;

Copello et al. 2009). Of the 14 studies with more than one group, participants were evenly

recruited into groups for 12 studies (de los Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-

Sosa 2006; Fals-Stewart et al. 2005; Hansson et al. 2006; Hansson et al. 2004; Latimer et al.

2003; Liddle et al. 2009; Nattala et al. 2010; O'Farrell et al. 2008; Rychtarik & McGillicuddy

2005; Slesnick & Prestopnik 2009; Vedel, Emmelkamp & Schippers 2008; Walitzer & Dermen

52

2004). Contamination was likely for six studies (Vedel, Emmelkamp & Schippers 2008;

Rychtarik & McGillicuddy 2005; Walitzer & Dermen 2004; Esposito-Smythers et al. 2006; de los

Angeles Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006; Howells & Orford 2006).

Effects

A meta-analysis using the most commonly reported outcomes (which were alcohol use among

problem drinkers and coping among their family members) was explored but judged

inappropriate, given the variability between studies in the outcomes reported. The most

commonly reported effect for problem drinkers was decreased alcohol consumption (Walitzer

& Dermen 2004; Slesnick & Prestopnik 2009; O'Farrell et al. 2008; Nattala et al. 2010; Latimer

et al. 2003; Boyd-Ball 2003; Doyle et al. 2003; Esposito-Smythers et al. 2006; Liddle et al. 2009;

Fals-Stewart et al. 2005). The most commonly reported effect for family members of problem

drinkers was improved coping (Howells & Orford 2006; Hansson et al. 2004; de los Angeles

Cruz-Almanza, Gaona-Marquez & Sanchez-Sosa 2006). Of the eight studies measuring family

functioning, four reported improvements in family functioning (Nattala et al. 2010; Vedel,

Emmelkamp & Schippers 2008; Slesnick & Prestopnik 2009; Liddle et al. 2009). In addition to

measures of effect, three studies measured level of participant engagement in treatment to be

55% (Dutcher et al. 2009), 83% (Landau et al. 2004), and 92% (O'Farrell et al. 2008). Two

interventions investigated the cost of the evaluated interventions: one based solely on the

length of sessions (Vedel, Emmelkamp & Schippers 2008) and the other calculated cost-

effectiveness ratios for participants using the change in percentage of days of heavy drinking

from baseline to follow-up (Fals-Stewart et al. 2005).

53

Discussion

Although an encouraging 18 of the 19 family-based interventions yielded a positive effect,

methodological deficiencies in evaluation designs across all studies resulted in less-than-

optimal evidence.

Methodological adequacy

The rating of studies across methodological review criteria was variable. For example, although

84% of studies were rated as strong for data collection methods, selection bias was rated as

weak for 47% of studies. Most studies did not control for confounders, even when identified.

Follow-up rates varied from 9% to 98%, and one third of studies performed an intent-to-treat

analysis. Methodological quality was similar for reviewed interventions targeting problem

drinkers and their family members, compared to interventions for family members of problem

drinkers only, although allocation bias was rated more strongly for the former and blinding

was rated more strongly for the latter. Variable reporting of an intervention evaluation makes

it difficult for the intervention to be replicated or adapted for other populations and settings

or for wider implementation.

Limitations of the available literature

Large variation in eligibility criteria for different studies limits their comparability.

Measurement of the primary criteria of an alcohol use disorder or problem was diverse for

studies that targeted problem drinkers and their family members. Comparability between

studies would be improved by using a standard measure of alcohol misuse, such as the AUDIT

(Saunders et al. 1993) or the Diagnostic and Statistical Manual of Mental Disorders, Fourth

Edition (DSM-IV) criteria (American Psychiatric Association 1994).

54

All studies (n = 19) used self-report measures. Non-self-report measures were used by six

studies. Reliance on self-report to measure health outcomes is problematic as the method is

prone to biases, even when bias is minimised by using psychometrically validated tools (Hogan

2003). A combination of objective non-self-report and self-report measures would increase

confidence in the validity of outcome findings. For example, information from medical records

has been shown to be both suitable and efficient for evaluating interventions targeting a range

of health and social outcomes (Samet et al. 2003; Landau et al. 2004; O'Farrell et al. 2008),

particularly if common challenges to its collection and use, such as limitations in data access

and poor data quality (Safran 1991), can be overcome.

Intervention costs were measured by two studies, but neither completed a full economic

evaluation. An economic evaluation is increasingly recognised as an integral component of any

evaluation because it provides relevant information on the potential efficiency of allocating

health care resources (Drummond & McGuire 2001). An integral component of any economic

evaluation is a rigorous assessment of both intervention costs and consequences compared to

current practice. Comparability of results between economic evaluation studies is further

made possible by the adoption of a commonly used validated health outcome measure such as

the quality adjusted life year or disability adjusted life year.

Interventions with potential to be tailored to Indigenous communities

This review only identified one intervention study targeting an Indigenous population (Native

Americans) (Boyd-Ball and Boyd-Ball, 2003), a study that was not methodologically strong. The

lack of evaluations of family-based interventions targeting Indigenous people is somewhat

surprising given that Indigenous family members are typically present at health services and

participate in communication about familial health problems with health practitioners

(McGrath et al. 2006; McCubbin 2006; King & Turia 2002). Therefore, their involvement in

55

programs to reduce alcohol-related harm fits with usual care practices. This review identified

family and cognitive-behavioral therapy (Latimer et al. 2003) and multidimensional family

therapy (Liddle et al. 2009) as effective and robustly evaluated problem drinker targeted

interventions that include a family member. Family members of problem drinkers experience

negative consequences of their relative’s drinking (Laslett et al. 2010; Kelly & Kowalyszyn 2003;

Seale et al. 2002), and therefore programs targeting family members in their own right that

also address problem drinker outcomes are likely to be acceptable and appropriate for delivery

in Indigenous communities to reduce alcohol-related harms. Effective programs identified by

this review, targeting family members and focusing on outcomes of the problem drinker and

those of their family member are Community Reinforcement and Family Training (CRAFT)

(Dutcher et al. 2009), coping skills training, and 12-step facilitation (Rychtarik & McGillicuddy

2005).

To ensure that these best evidence family-based approaches are appropriate and acceptable

for delivery to Indigenous people, they should be adapted for integration into Indigenous-

specific health care in collaboration with locally targeted Indigenous communities.

Potential limitations of the review

Although a rigorous and thorough search strategy was used, there is a possibility that the

review did not locate all relevant studies. Relevant intervention evaluations may have been

misclassified; however, a sufficient agreement between blinded coders ( = 0.58) suggests

otherwise. Last, because evaluations with statistically significant findings are more likely to be

published it is possible that the published evaluations reviewed overestimate the

interventions’ true effectiveness (Dickersin et al. 1987; Easterbrook et al. 1991).

56

Conclusions

Although family-based approaches appear effective in engaging problem drinkers into

treatment and reducing their risk of alcohol-related harms, the evidence-base for their cost-

effectiveness would be strengthened by evaluation studies that recruit more representative

samples, include confounding variables in analyses, improve consent and follow-up rates, and

conduct high quality economic evaluations. Given the central role that family relationships play

in reinforcing behaviour and maintaining social cohesion in Indigenous communities, family-

based approaches offer considerable promise for reducing alcohol-related harms among

Indigenous peoples. Family-based interventions are more likely to be acceptable, appropriate

and effective for Indigenous peoples if (a) adapted with the input of Indigenous community

members (Masotti et al. 2006); (b) the involvement of family members who are themselves

problem drinkers is not automatically excluded, because their exclusion is not practical in the

context of routine delivery of health care services due to clustering of alcohol problems within

racial minority family groups (Seale et al. 2010); (c) therapists delivering the intervention are

trained and supervised to optimise intervention fidelity (Miller et al. 2006); and (d) the

intervention is manualized for integration into health service protocols and procedures but has

sufficient flexibility to meet the needs of individual clients (Liddle 2004).

57

Points of clarification for Paper 1

The Journal of Studies on Alcohol and Drugs owns the copyright of this published paper. The

points of clarification have been added to provide additional information about the research

for this thesis without modifying the content of the published paper.

Resolution of classification discrepancies

Coders met to discuss classification discrepancies. Consensus was reached through re-

examining the identified studies and agreeing on the appropriate classification.

58

Paper 2

Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut-off scores for at-

risk, high-risk and likely dependent drinkers using measures of

agreement with the 10-item Alcohol Use Disorders Identification Test

Bianca Calabria1, Anton Clifford2,3, Anthony P. Shakeshaft1, Katherine M. Conigrave1,4,5,

Lynette Simpson6, Donna Bliss7, Julaine Allan8

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South

Wales, Australia

2. Institute for Urban Indigenous Health, University of Queensland, Bowen Hills, Queensland, Australia

3. Queensland Alcohol and Drug Research and Education Centre, University of Queensland, Brisbane,

Australia

4. Drug Health Services, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South

Wales, Australia

5. Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia

6. Drug Health Services, South Western Sydney Local Health District, Croydon Health Centre, Croydon,

New South Wales, Australia.

7. Yoorana Gunya Family Healing Centre Aboriginal Corporation, Forbes, New South Wales, Australia

8. The Lyndon Community, Orange, New South Wales, Australia

Paper 2 has been submitted to Addiction Science & Clinical Practice (Calabria et al. submitted-

b).

59

Copyright Statement



Calabria, B, Clifford, A, Shakeshaft, A, Conigrave, K, Simpson, L, Bliss, D & Allan, J submitted,

'Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut-off scores for at-risk, high-risk and

likely dependent drinkers using measures of agreement with the 10-item AUDIT', Addiction

Science & Clinical Practice.


60

Preamble

Paper 1 identified Community Reinforcement and Family Training (CRAFT) as a family-based

intervention that has considerable potential to reduce alcohol-related harms among

Indigenous Australians and that has some evidence for its effectiveness (Calabria et al. 2012).

Although the study evaluating CRAFT identified in Paper 1 (Dutcher et al. 2009) was

methodologically weak, primarily due to its non-randomised design, failure to blind outcome

assessors and its low follow-up rates, CRAFT offers considerable promise for implementation in

Indigenous communities for at least three main reasons. Firstly, controlled research published

outside of the Paper 1 review timeframe has shown CRAFT to be superior to

Alcoholics/Narcotics Anonymous and the Johnson Institute Intervention for engaging

treatment resistant individuals into treatment (Miller, Meyers & Tonigan 1999; Roozen, de

Waart & van der Kroft 2010; Meyers et al. 2002), and the CRAFT approach has demonstrated

ability to be tailored for delivery across different drug types, family member types, and cultural

groups (Meyers, Villanueva & Smith 2005; Lopez Viets 2008; Villarreal 2008). Second, CRAFT

offers a flexible mode of delivery: trained therapists choose from a selection of manualised

evidence-based therapeutic approaches and can apply them to individual clients (Smith &

Meyers 2007) who are likely to have complex comorbidities (Kelly 2006). Third, multiple family

members can be included in the program, allowing for Indigenous peoples’ extended family

groups and their holistic concept of health, in which the health of individuals is linked to the

health of families and communities (Brady 2004).

To increase the likelihood that individuals with a particular health risk behaviour will be

identified and offered an appropriate intervention, and that the effect of the intervention can

be accurately assessed, reliable and valid measures should be identified and used. The Alcohol

Use Disorders Identification Test (AUDIT) was designed as a cross-cultural screening

instrument and has been recommended for use in Indigenous health care settings (Babor et al.

61

2001; Saunders et al. 1993); however the time it takes to complete all 10-items has proven to

be a barrier to delivery. Although appropriate cut-off scores have been identified for other

cultural groups (Cherpitel 1998; Cherpitel & Clark 1995), Indigenous-specific cut-off scores

have not been published in the peer-reviewed literature. Paper 2 identifies Indigenous-specific

cut-off scores for two shorter versions of AUDIT, AUDIT-C and AUDIT-3, relative to cut-off

scores for the full 10-item AUDIT (Calabria et al. submitted-b). Indigenous-specific cut-off

scores for AUDIT-C and AUDIT-3 could be used to more accurately and efficiently identify

problem drinkers for enrolment into Aboriginal-specific family-based intervention programs

aimed at reducing alcohol-related harms, and to more accurately assess changes in their levels

of alcohol consumption and risk of harm before and after intervention delivery.

62

Abstract

Background: The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item alcohol

screener that has been recommended for use in Aboriginal health care settings. The time it

takes respondents to complete AUDIT, however, has proven to be a barrier to its routine

delivery. Two shorter versions, AUDIT-C and AUDIT-3, have been used as screening

instruments in health care settings. This paper aims to identify the AUDIT-C and AUDIT-3 cut-

off scores that most closely identify individuals classified as being at-risk drinkers, high-risk

drinkers or likely alcohol dependent by the 10-item AUDIT.

Methods: Two cross-sectional surveys were conducted in June 2009 to May 2010 and July 2010

to June 2011. Aboriginal Australian participants (n = 136) were recruited through an Aboriginal

Community Controlled Health Service and a community-based drug and alcohol treatment

agency in rural New South Wales (NSW), and through community-based Aboriginal groups in

Sydney (NSW). Sensitivity, specificity, and positive and negative predictive values of each score

on the AUDIT-C and AUDIT-3 were calculated, relative to standard cut-off scores on the 10-

item AUDIT for at-risk, high-risk and likely dependent drinkers. Receiver operating

characteristic curve analysis was conducted to measure the detection characteristics of AUDIT-

C and AUDIT-3 for at-risk, high-risk and likely dependent drinkers, as classified by the 10-item

AUDIT.

Results: Recommended cut-off scores for Aboriginal Australians are: at-risk drinkers AUDIT-C ≥

5, AUDIT-3 ≥ 1; high-risk drinkers AUDIT-C ≥ 6, AUDIT-3 ≥ 2; and likely dependent drinkers

AUDIT-C ≥ 9, AUDIT-3 ≥ 3. Adequate sensitivity and specificity were achieved for

recommended cut-off scores for AUDIT-C and AUDIT-3, relative to the 10-item AUDIT. All areas

under the receiver operating characteristic curves were above 0.90.

Conclusions: Identified cut-off scores for AUDIT-C and AUDIT-3 have potential to detect

Aboriginal Australians as being problem drinkers in Aboriginal-specific health care settings.

63

Background

Problem drinkers are at high risk of causing physical and psychological harm to themselves,

their family and their community (Laslett et al. 2010). Although Aboriginal Australians are

more likely to abstain from drinking alcohol than other Australians, a greater proportion of

Aboriginal Australians who drink alcohol do so to levels that increase their risk of alcohol-

related harm (Australian Department of Human Services and Health 1995; Calabria et al.

2010). Screening Aboriginal people to assess their level of alcohol consumption is recognised

as an important initial step for determining their risk of alcohol-related harm and need for

alcohol intervention (Australian Government Department of Health and Ageing 2004;

Australian Government Department of Health and Ageing 2007; NACCHO and the Chronic

Disease Alliance of NGOs 2008). Alcohol screening can also be effective for engaging Aboriginal

patients in discussions about their drinking (Clifford & Shakeshaft 2011) and can result in

reduced alcohol consumption independent of intervention (Conigliaro, Lofgren & Hanusa

1998; Jenkins, McAlaney & McCambridge 2009).

The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health

Organization as a cross cultural screening instrument for problematic alcohol use (Saunders et

al. 1993; Babor et al. 2001). AUDIT has ten items comprising three domains: recent alcohol

use; alcohol dependence symptoms; and alcohol-related problems (Babor et al. 2001). Cut-off

scores aim to identify non-drinkers, low-risk drinkers, at-risk drinkers, high-risk drinkers and

likely dependent drinkers (Babor et al. 2001; Conigrave, Hall & Saunders 1995; Tsai et al. 2005).

AUDIT has high internal consistency across diverse samples and settings (median alpha = 0.83)

and demonstrated validity for the English language version (Reinert & Allen 2007).

The Alcohol Treatment Guidelines for Indigenous Australians recommend using AUDIT to

screen for alcohol use problems among Aboriginal Australians (Australian Government

64

Department of Health and Ageing 2007). The Guideline’s recommended classification scores

are 0-7 for non-drinkers or low-risk drinkers, 8-12 for at-risk drinkers, and 13+ for high-risk

drinkers. A key limitation of AUDIT for routine screening in Aboriginal-specific (Brady et al.

2002; Clifford & Shakeshaft 2011) and mainstream (Hearne, Connolly & Sheehan 2002) health

care settings has been the time it takes respondents to complete all 10 items. Two shorter

versions of AUDIT, AUDIT-C (comprising the first three questions of AUDIT) and AUDIT-3 (the

third question of AUDIT), have been shown to perform well to identify risky drinking when

compared with a ‘gold standard’ measure of problematic alcohol consumption, for example

Diagnostic and Statistical Manual of Mental Disorders alcohol dependence criteria (American

Psychiatric Association 1994), in non-Indigenous-specific health care settings (Reinert & Allen

2007),.

Despite evidence from qualitative studies that shorter versions of AUDIT are more feasible to

deliver in Aboriginal-specific primary health care settings (Brady et al. 2002; Clifford &

Shakeshaft 2011; Brit et al. 2009), and the shorter versions of AUDIT being used to measure

Aboriginal Australians’ drinking in general practice settings (Brit et al. 2009), no published

studies have identified cut-off scores specifically for Aboriginal Australians. This paper aims to

identify AUDIT-C and AUDIT-3 cut-off scores for detecting problematic alcohol use, as defined

by the 10-item AUDIT, among Aboriginal clients in health care settings.

Methods

Ethics

Ethics approval for the study was granted by: the Human Research Ethics Committee (HREC),

University of New South Wales (NSW), Sydney; South West Area Health Service HRECs, Sydney;

and the Aboriginal Health and Medical Research Council (AH&MRC) Ethics Committee, NSW.

65

The study was also either formally approved by the board of the participating Aboriginal

Community Controlled Health Services (ACCHSs) or had a representative of the ACCHS on its

steering committee. All participants were provided with study and consent information.

Setting and participants

A convenience sample of Australian Aboriginal participants was recruited through a NSW rural

ACCHS and a rural community-based drug and alcohol treatment agency from July 2010 to

June 2011, as part of a study investigating the acceptability of an evidence-based cognitive

behavioural alcohol intervention to Aboriginal people (Calabria et al. 2013). Participants were

also recruited through existing Aboriginal community-based groups in metropolitan Sydney

from June 2009 to May 2010, as part of a pilot study of community education and brief

intervention (Conigrave et al. 2012). Participants recruited in rural NSW were reimbursed $A40

to cover their out-of-pocket expenses for involvement in the study. Reimbursement was not

available for participants in the Sydney based sample.

Questionnaires

A version of the 10-item AUDIT which has been modified for, and is acceptable to, Aboriginal

Australians (Table 1) (Conigrave et al. 2012), was self-completed by participants, with literacy

support available. Total scores range from zero to forty, with higher scores indicating more

problematic alcohol use. Cut-off scores recommended by the Alcohol Treatment Guidelines for

Indigenous Australians (Australian Government Department of Health and Ageing 2007) were

used to classify drinker status. Given Indigenous Australians who drink alcohol are more likely

to do so at levels that places them at increased risk of alcohol-related harm than the general

Australian population (Australian Department of Human Services and Health 1995), the

Guideline’s high-risk drinker classification was divided into high-risk drinkers and likely

dependent drinkers (Babor et al. 2001) to more clearly investigate this group. Therefore

66

participants were classified as: non-drinkers (score = 0); low-risk drinkers (score = 1-7); at-risk

drinkers (score = 8-12); high-risk drinkers (score = 13-19); or likely dependent drinkers (score ≥

20).

Table 1. Alcohol Use Disorders Identification Test (AUDIT) adapted wording for


Adapted Aboriginal-specific

AUDIT items (Conigrave et

al. 2012)

Original AUDIT item Response Score

1. How often do you drink? How often do you have a

drink containing alcohol?

Never

Monthly or less

2-4 times a month

2-3 times a week

4 or more times a week

0

1

2

3

4

2. When you have a drink, how

many do you usually have in

one day?

How many standard drinks

containing alcohol do you

have on a typical day when

drinking?

1 or 2

3 or 4

5 or 6

7-9

10 or more

0

1

2

3

4

3. How often do you have six

or more drinks on one day?

How often do you have six

or more drinks on one

occasion?

Never

Monthly or less

Monthly

Weekly

Daily or almost daily

0

1

2

3

4

4. In the last year, how often

have you found you weren’t

able to stop drinking once

you started?

During the past year, how

often have you found that

you were not able to stop

drinking once you had

started?

Never

Monthly or less

Monthly

Weekly


0

1

2

3

4


has drinking got in the way

of doing what you need to

do?


often have you failed to do

what was normally expected

of you because of drinking?

Never

Monthly or less

Monthly

Weekly


0

1

2

3

4


have you needed a drink in

the morning to get yourself

going?


often have you needed a

drink in the morning to get

yourself going after a heavy

drinking session?

Never

Monthly or less

Monthly

Weekly


0

1

2

3

4


have you felt bad about

your drinking?


often have you had a feeling

of guilt or remorse after

drinking?

Never

Monthly or less

Monthly

Weekly


0

1

2

3

4

67

Adapted Aboriginal-specific

AUDIT items (Conigrave et

al. 2012)

Original AUDIT item Response Score


have you had a memory

lapse or blackout because of

your drinking?

During the past year, have

you been unable to

remember what happened

the night before because

you had been drinking?

Never

Monthly or less

Monthly

Weekly


0

1

2

3

4

9. Have you injured yourself or

anyone else because of your

drinking?

Have you or someone else

been injured as a result of

your drinking?

No

Yes, but not in the past

year

Yes, during the past year

0

2

4

10. Has anyone (family, friend,

doctor) been worried about

your drinking or asked you

to cut down?

Has a relative or friend,

doctor or other health

worker been concerned

about your drinking or

suggested you cut down?

No

Yes, but not in the past

year


0

2

4

AUDIT-C assesses frequency and quantity of alcohol use, and frequency of heavy drinking (six

or more drinks on one day) (Table 1, items 1-3). Total scores range from zero to twelve. As

with the 10-item AUDIT, higher scores indicate more problematic alcohol use. AUDIT-3 (the

third item of the 10-item AUDIT) measures frequency of heavy drinking (Table 1, item 3). Total

scores range from zero to four: greater consumption of alcohol is reflected in a higher score.

Exclusion criterion

Participants who did not complete all 10 AUDIT items were excluded, except for those who

appropriately did not answer item two because they indicated being a non-drinker on item

one. In that circumstance, item two was scored zero, reflecting the participant’s status as a

non-drinker.

Data analysis

Sensitivity, specificity, and positive and negative predictive values (Lemeshow et al. 1990) of

each score on the AUDIT-C and AUDIT-3 were calculated, relative to cut-off scores on the 10-

68

item AUDIT: at-risk drinkers (score ≥ 8); high-risk drinkers (score ≥ 13); and likely dependent

drinkers (score ≥ 20) (Australian Government Department of Health and Ageing 2007; Babor et

al. 2001; Conigliaro, Lofgren & Hanusa 1998) (see Appendix B for formulae used in analysis).

For this study, sensitivity is the proportion of respondents identified as risky drinkers on the

10-item AUDIT who are also identified as risky drinkers on AUDIT-C and/or AUDIT-3. Specificity

is the proportion of respondents identified as non-risky drinkers on the 10-item AUDIT who are

also identified as non-risky drinkers on AUDIT-C and/or AUDIT-3. The positive predictive value

is the proportion of respondents identified as risky drinkers on AUDIT-C and/or AUDIT-3 who

are also identified as risky drinkers on the 10-item AUDIT. The negative predictive value is the

proportion of respondents identified as non-risky drinkers on AUDIT-C and/or AUDIT-3 who are

also identified as non-risky drinkers on the 10-item AUDIT (Lemeshow et al. 1990).

Factors specific to Aboriginal health care settings were used to guide decisions about optimal

cut-off scores. Since Aboriginal drinkers are more likely to drink at risky levels than non-

Aboriginal drinkers (Australian Department of Human Services and Health 1995) there is a

higher probability that Aboriginal drinkers will require an alcohol-specific intervention

(Australian Government Department of Health and Ageing 2007). Consequently, higher

sensitivity (to detect true positive cases) took preference over higher specificity (to detect true

negative cases). For dependent drinkers, minimising the number of people who receive

referral unnecessarily is important given their treatment is relatively expensive and typically

involves multiple health care providers and inpatient care (Australian Government Department

of Health and Ageing 2007). Consequently, higher specificity (to detect true negative cases)

was favoured over higher sensitivity (to detect true positive cases) for optimal cut-off scores in

relation to likely alcohol dependence.

69

Receiver operating characteristic (ROC) curve analysis was conducted to measure the

detection characteristics of AUDIT-C and AUDIT-3 for at-risk, high-risk and likely dependent

drinkers identified by the 10-item AUDIT (Metz 1978). A value of one for the area under the

ROC (AUROC) curve represents a test with 100% accuracy. Ninety five percent confidence

intervals were calculated.

Data analysis used IBM® SPSS® Statistics 19 (IBM 2010), and Microsoft® Excel 2007 (Microsoft

2007).

Results

Sample characteristics

One hundred and fifty seven Aboriginal Australian participants took part in the surveys, 21 of

whom did not answer all 10 items of AUDIT. Of the 136 participants in the final sample (71%

from rural NSW and 29% from Sydney), 11% were aged 18 to 24 years, 24% were aged 25 to 34

years, 27% were aged 35 to 44 years, 25% were aged 45 to 55 years, 10% were 55 years or

older (3% did not indicate their age), 49% were male.

Alcohol use

AUDIT scores of participants ranged from zero to forty (median = 8.0; standard deviation =

11.0). Applying standard cut-off scores for the 10-item version of AUDIT resulted in the

following distribution of participants across risk categories: 15% were non-drinkers (score = 0);

31% were low-risk drinkers (score = 1-7); 15% were at-risk drinkers (score = 8-12); 16% were

high-risk drinkers (score = 13-19); and 22% were likely dependent drinkers (score ≥ 20). There

were more at-risk drinkers in Sydney (30%) than rural NSW (9%), and more likely dependent

drinkers in rural NSW (30%), compared to Sydney (3%). Of the total sample, 73 (54%) were

70

classified as being at least at-risk drinkers (AUDIT score ≥ 8) and 38% (n = 52) were classified as

being at least high-risk drinkers (AUDIT score ≥ 13).

The distribution of participants across risk categories varied for males (and females): 10%

(21%) were non-drinkers; 18% (44%) were low-risk drinkers; 21% (10%) were at-risk drinkers;

16% (15%) were high-risk drinkers; and 34% (10%) were likely dependent drinkers.

At-risk drinkers

The AUROC for AUDIT-C was high for drinkers classified as being at increased risk by the 10-

item AUDIT (0.93, 95%CI = 0.89 – 0.97) (Figure 1). The optimal combination of sensitivity and

specificity for at-risk drinkers was reached using a cut-off score of ≥ 5 for AUDIT-C. This cut-off

score identified 85% of at-risk drinkers, as classified by the 10-item AUDIT, and 81% of those

identified as not being at increased risk. The positive and negative predictive values were both

greater than 0.80 (Table 2).

The AUROC for AUDIT-3 was also high for drinkers classified as being at increased risk by the

10-item AUDIT (0.91, 95%CI = 0.85 – 0.96) (Figure 1). The optimal combination of sensitivity

and specificity for at-risk drinkers was reached using a cut-off score of ≥ 1 for AUDIT-3. This

cut-off score identified 95% of at-risk drinkers, as classified by the 10-item AUDIT, and 65% of

those identified as not being at increased risk drinkers. A lower positive predictive value (0.76)

than for AUDIT-C, however, indicated a number of false positive cases would be identified

relative to the 10-item AUDIT. A cut-off score of ≥ 2 reduces the number of false positive cases

(positive predictive value = 0.91), but decreases the number of true positive cases (sensitivity =

0.81) (Table 2).

71

Table 2. Measures of agreement for AUDIT-C and AUDIT-3 cut-off scores

Sensitivity Specificity Positive

predictive

value

Negative

predictive

value


predictive

value

Negative

predictive

value


predictive

value

Negative

predictive

value

Score At-risk drinker (10-item AUDIT score ≥ 8) High-risk drinker (10-item AUDIT score ≥ 13) Likely dependent drinker (10-item AUDIT score ≥ 20)

AUDIT-C

≥ 1 0.99 0.43 0.67 0.96 0.98 0.32 0.47 0.96 1.00 0.26 0.28 1.00

≥ 2 0.97 0.56 0.72 0.95 0.98 0.43 0.52 0.97 1.00 0.35 0.30 1.00

≥ 3 0.97 0.63 0.76 0.95 0.98 0.49 0.54 0.98 1.00 0.40 0.32 1.00

≥ 4 0.92 0.70 0.78 0.88 0.96 0.57 0.58 0.96 1.00 0.47 0.35 1.00

≥ 5 0.85 0.81 0.84 0.82 0.92 0.69 0.65 0.94 0.97 0.58 0.39 0.98

≥ 6 0.79 0.86 0.87 0.78 0.88 0.75 0.69 0.91 0.97 0.64 0.43 0.99

≥ 7 0.67 0.98 0.98 0.72 0.81 0.90 0.84 0.88 0.93 0.79 0.56 0.98

≥ 8 0.51 1.00 1.00 0.64 0.63 0.95 0.89 0.81 0.87 0.90 0.70 0.96

≥ 9 0.44 1.00 1.00 0.61 0.58 0.98 0.94 0.79 0.87 0.94 0.81 0.96

≥ 10 0.32 1.00 1.00 0.56 0.42 0.99 0.96 0.73 0.63 0.96 0.83 0.90

≥ 11 0.19 1.00 1.00 0.52 0.27 1.00 1.00 0.69 0.47 1.00 1.00 0.87

≥ 12 0.10 1.00 1.00 0.49 0.13 1.00 1.00 0.65 0.23 1.00 1.00 0.82

AUDIT-3

≥ 1 0.95 0.65 0.76 0.91 0.98 0.52 0.56 0.98 1.00 0.42 0.33 1.00

≥ 2 0.81 0.90 0.91 0.80 0.92 0.80 0.74 0.94 0.97 0.66 0.45 0.99

≥ 3 0.47 0.97 0.94 0.61 0.62 0.95 0.89 0.80 0.93 0.92 0.78 0.98

≥ 4 0.16 1.00 1.00 0.51 0.23 1.00 1.00 0.68 0.40 1.00 1.00 0.85

72

Figure 1. ROC curve for at-risk drinker (AUDIT score ≥ 8)

High-risk drinkers

The AUROC for AUDIT-C was high for drinkers classified as being at high risk by the 10-item

AUDIT (0.92, 95%CI = 0.87 – 0.97) (Figure 2). The optimal combination of sensitivity and

specificity for high-risk drinkers was reached using a cut-off score of ≥ 6 for AUDIT-C. This cut-

off score identified 88% of high-risk drinkers, as classified by the 10-item AUDIT, and 75% of

those identified as not being at high risk. The positive predictive value (0.69) indicated a

number of false positive cases, relative to the 10-item AUDIT. If the cut-off score was increased

to ≥ 7 the number of false positive cases would be reduced (positive predictive value = 0.84),

but the number of true positive cases would be reduced (sensitivity = 0.88 using a cut-off score

of ≥ 6 for AUDIT-C and 0.81 using a cut-off score of ≥ 7 for AUDIT-C) (Table 2).

73

The AUROC for AUDIT-3 was also high for drinkers classified as being high risk by the 10-item

AUDIT (0.92, 95%CI = 0.87 – 0.96) (Figure 2). The optimal combination of sensitivity and

specificity for high-risk drinkers was reached using a cut-off score of ≥ 2 for AUDIT-3. This cut-

off score identified 92% of high-risk drinkers, as classified by the 10-item AUDIT, and 80% of

those identified as not being at high-risk. The positive and negative predictive values were 0.74

and 0.94, respectively (Table 2).

Figure 2. ROC curve for high-risk drinker (AUDIT score ≥ 13)

Likely dependent drinkers

The AUROC for AUDIT-C was high for respondents classified as being likely dependent drinkers

by the 10-item AUDIT (0.95, 95%CI = 0.91 – 0.99) (Figure 3). The optimal combination of

sensitivity and specificity for likely dependent drinkers was reached using a cut-off score of ≥ 9

for AUDIT-C. This cut-off score identified 87% of likely dependent drinkers, as classified by the

74

10-item AUDIT, and 94% of those identified as unlikely to be dependent drinkers. Positive and

negative predictive values were both above 0.80 (Table 2).

The AUROC for AUDIT-3 was also high for respondents classified as being likely dependent

drinkers by the 10-item AUDIT (0.96, 95%CI = 0.92 – 0.99) (Figure 3). The optimal combination

of sensitivity and specificity for likely dependent drinkers was reached using a cut-off score of

≥ 3 for AUDIT-3. This cut-off score identified 93% of likely dependent drinkers, as classified by

the 10-item AUDIT, and 92% of those identified as unlikely to be dependent drinkers. Positive

and negative predictive values were 0.78 and 0.98, respectively (Table 2).

Figure 3. ROC curve for likely dependent drinker (AUDIT score ≥ 20)

75

Discussion

Summary of results

This is the first study to identify the sensitivity and specificity, and positive and negative

predictive values, of shorter forms of the 10-item AUDIT questionnaire for urban and rural

Aboriginal Australians. When using AUDIT-C to identify at-risk, high-risk and likely dependent

drinkers, as classified by the 10-item AUDIT, recommended cut-off scores are ≥ 5, ≥ 6 and ≥ 9,

respectively. When using AUDIT-3 to identify at-risk, high-risk and likely dependent drinkers, as

classified by the 10-item AUDIT, recommended cut-off scores are≥ 1, ≥ 2 and ≥ 3, respectively.

All AUROC were above 0.90 indicating good performance of both AUDIT-C and AUDIT-3 in

identifying the at-risk, high-risk and likely dependent drinkers that were classified as such by

the 10-item AUDIT.

Implications

These recommended AUDIT-C and AUDIT-3 cut-off scores for detecting at-risk, high-risk or

likely dependent Aboriginal Australian drinkers are generally higher than those identified for

non-Aboriginal Australian populations (Reinert & Allen 2007), although one study found

comparable cut-off scores for at-risk drinkers in a primary care sample (Seale et al. 2006).

These differences in cut-off scores potentially reveal a unique response pattern by Aboriginal

Australians which may reflect the fact that participants in this study were asked questions

about drinks. Participants in this study were asked questions about drinks, rather than

standard drinks, to cut down the need for mental arithmetic in a population that has often

been educationally disadvantaged. The Australian standard drink is 10 g of ethanol whereas a

can of beer, for example, is approximately 1.3 standard drinks, and most people drink wine in

at least 1.8 standard drink serves (National Health and Medical Research Council 2009). It is

76

unclear how the participants’ calculation of the number of drinks they consume compares to

these standard drink definitions (Lee, Dawson & Conigrave in press).

The two results for which recommended cut-off scores are most difficult to determine are

AUDIT-3 cut-off scores for at-risk drinkers and AUDIT-C cut-off scores for high-risk drinkers.

The recommended cut-off scores prioritise higher sensitivity over higher specificity; however,

this creates an issue of false positives which may result in additional work following up cases to

distinguish false positives from true positives. If brief intervention is done appropriately and

respectfully, however, then this checking process can be done as part of a reminder of current

recommended drinking guidelines. A larger study may be able to more definitively determine

appropriate cut-off scores in these cases.

From a clinical services perspective, a decision about which screening instrument is most

appropriate for Aboriginal clients would be required in consultation with Aboriginal health

professionals and/or Aboriginal communities. For at-risk drinkers, AUDIT-C has a greater

specificity, albeit a slightly lower sensitivity than AUDIT-3 (sensitivity: 0.85 and 0.95,

respectively; specificity: 0.81 and 0.65, respectively) indicating a slight preference for using

AUDIT-C to identify at-risk Aboriginal drinkers. For high-risk and likely dependent Aboriginal

drinkers using either AUDIT-C or AUDIT-3 would be appropriate, based on similar sensitivities

and specificities for the two measures. The decision may be made on practical grounds:

whether saving time during the screening process or in following-up on positive results is more

important. If screening is automated, with touch-screen computers for example, then the

three item AUDIT-C (or indeed the 10-item AUDIT) may be desirable given its greater

specificity. If screening is manual, however, or screening is also required for a number of other

health risk factors (e.g. smoking, nutrition and obesity), asking only a single alcohol question

(AUDIT-3) may be preferred, with a later discussion about drinking and other health risk

77

factors during the clinical interview. Community consultation could help to determine which of

AUDIT-C or AUDIT-3 is more acceptable to Aboriginal people in different circumstances.

Limitations

A convenience sample was used. This method of recruitment which resulted in a sample of

Aboriginal Australians likely to access the participating health services or community groups,

probably resulted in low recruitment of treatment resistant individuals with alcohol problems.

Self-report data are prone to bias, even when this is minimised by using psychometrically

validated tools (Hogan 2003). Self-reports of alcohol consumption are more likely to be

accurate under optimal conditions: when participants are alcohol free; when assured

confidentiality; when questions are clear; and in situations not likely to promote under-

reporting (e.g., clinical compared to legal) (National Institute on Alcohol Abuse and Alcoholism

1995). These conditions were likely to be met by our study.

Although it has been recommended that measures to detect alcohol misuse be tested

separately for men and women (Reinert & Allen 2007), this study did not attempt to do so due

to the small number of men and women in each group. Given lower cut-off scores have been

recommended for women, compared to men, in other populations (Reinert & Allen 2007),

these analyses would be worthwhile undertaking for studies with larger sample sizes.

The method used in this study of comparing results on AUDIT-C and AUDIT-3 to the 10-item

AUDIT differs from other validation studies that compare the short versions of AUDIT with a

‘gold standard’ measure (Reinert & Allen 2007). The method for this study, however, was

required because a ‘gold standard’ measure for Aboriginal Australians is not available. The 10-

item AUDIT questionnaire was used because it has been recommended for use in Aboriginal

health care settings (Australian Government Department of Health and Ageing 2007), despite

78

not having been formally validated itself with Aboriginal Australian populations. Although

comparison with other validation studies should be made with caution, because different

results may have been found if AUDIT-C and AUDIT-3 were evaluated against some other ‘gold

standard measure’, any such differences are likely to be minor.

The AUDIT scoring was developed at a time when international and Australian drinking

guidelines were more liberal. Further study is required to see if the current recommended

AUDIT cut-off scores (and hence AUDIT-C and AUDIT-3 cut-off scores) should be revised

downward, to allow detection of anyone drinking over current recommended limits (e.g. 20 g

daily or 40 g on any one occasion in Australia) (National Health and Medical Research Council

2009), and whether the use of open ended responses to questions one and two result in more

accurate drink risk identification.

Finally, the diagnostic error of the 10-item AUDIT questionnaire is expected to be highly

correlated with the error of AUDIT-C and AUDIT-3 and, therefore, the AUROC analyses are

likely to be biased upwards. AUROCs in this study ranged from 0.91 to 0.96, and therefore if

the results were revised downwards to account for bias they are likely to still be comparable to

other validation studies (Reinert & Allen 2007).

Conclusions

The optimal performance of AUDIT-C and AUDIT-3 in detecting at-risk, high-risk and likely

dependent Aboriginal Australian drinkers, as classified by the 10-item AUDIT, was achieved

using cut-off scores of AUDIT-C ≥ 5 and AUDIT-3 ≥ 1, AUDIT-C ≥ 6 and AUDIT-3 ≥ 2, and AUDIT-

C ≥ 9 and AUDIT-3 ≥ 3, respectively. These findings provide an empirical basis for defining cut-

off scores, which complements existing evidence that both short form versions of AUDIT are

79

suitable for routinely screening Aboriginal Australian clients for alcohol problems in Aboriginal

specific health care settings.

Acknowledgements

We would like to thank the many colleagues and community members who helped with this

research. We are also grateful for the statistical advice provided by Dr Tim Slade. This work

was supported by the Australian Government Department of Health and Ageing, a linkage

grant from the Australian Research Council and by a grant from the National Drug Research

Institute, Curtin University. This research was conducted without input from the funders.

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Paper 3

Tailoring a family-based alcohol intervention for Aboriginal Australians,

and the experiences and perceptions of health care providers trained in

its delivery

Bianca Calabria1, Anton Clifford2,3, Miranda Rose4, Anthony Shakeshaft1

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South

Wales, Australia

2. Institute for Urban Indigenous Health, University of Queensland, Bowen Hills, Queensland, Australia

3. Queensland Alcohol and Drug Research and Education Centre, University of Queensland, Brisbane,

Australia

3. University of Technology, Sydney, New South Wales, Australia

Paper 3 has been submitted to Health Service Research (Calabria et al. submitted-a) .

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Copyright Statement



Calabria, B, Clifford, A, Rose, M & Shakeshaft, A submitted, 'Tailoring a family-based alcohol

intervention for Aboriginal Australians, and the experiences and perceptions of healthcare

practitioners trained in its delivery', Health Services Research.


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Preamble

The identification of Indigenous-specific AUDIT-C and AUDIT-3 cut-off scores in Paper 2 gives

some certainly that alcohol consumption risk levels can be accurately assigned to Indigenous

clients who present at health care services which, in turn, increases the likelihood that their

health care needs can be more precisely met. Providing Indigenous-specific interventions

aimed at reducing alcohol-related harms to Indigenous Australians, who are screened using

Indigenous-specific cut-off scores for AUDIT-C and AUDIT-3, will help address Indigenous-

specific needs more cost-effectively.

Paper 1 identified CRAFT as a family-based alcohol intervention with potential to be tailored

for Indigenous people, when modified in consultation with targeted community members

(Calabria et al. 2012). CRAFT targets family members of problem drinkers and teaches them

how to support their problem drinking relative to reduce their alcohol consumption, increase

participation in rewarding non-drinking behaviours, and to engage in appropriate treatment.

CRAFT also has a focus on the family member’s personal safety and increasing their own

wellbeing (Smith & Meyers 2007). Although CRAFT has been successfully adapted for use

among Native Americans (Miller, Meyers & Hiller-Sturmhofel 1999), it has not been evaluated

with Indigenous people in other countries. The modified CRAFT program used with Native

Americans was consistent with Indigenous holistic concepts of health and wellbeing by

emphasising the connectedness with family, community and spirituality in the treatment

approach. The suitability of this approach for Native Americans reflects that it is highly likely to

be acceptable and feasible if adapted for Indigenous communities elsewhere.

CRAFT uses cognitive-behavioural principles and procedures modelled from the Community

Reinforcement Approach (CRA). CRA is an evidence-based cognitive-behavioural intervention

aimed at working with problem drinkers to reduce their alcohol consumption and has a focus

83

on changing behavioural patterns to spend more time in enjoyable non-drinking situations

(Meyers & Smith 1995; Miller & Wilbourne 2002). Given the parallels between CRAFT and CRA,

CRA would be a highly relevant treatment for relatives of individuals participating in CRAFT.

For CRA and CRAFT to be feasible for delivery to Indigenous Australians, both interventions

need to be acceptable to the Indigenous people who are likely to access the interventions and

to the health care providers who will deliver the programs.

Paper 3 presents health care providers perceptions of the applicability of CRA and CRAFT for

Indigenous Australians and suggestions for suitable modifications to the interventions to

increase their appropriateness. Paper 3 also presents the experiences of health care providers

participating in an internationally recognised counsellor certification program for CRA and

CRAFT (Calabria et al. submitted-a).

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Abstract

Objective. To describe the process of tailoring the Community Reinforcement Approach (CRA)

and Community Reinforcement and Family Training (CRAFT) for delivery to Aboriginal

Australians, explore the perceptions of health care providers participating in the tailoring

process, and their experiences of participating in CRA and CRAFT counselor certification.

Data Sources/Study Setting. Notes recorded from eight working group meetings with 22 health

care providers of a drug and alcohol treatment agency and Aboriginal Community Controlled

Health Service (November 2009-February 2013), and transcripts of semi-structured interviews

with seven health care providers participating in CRA and CRAFT counselor certification (May

2012).

Study Design. Qualitative content analysis was used.

Data Collection/Extraction Methods. Data from working group meeting notes and interview

transcripts were categorized into key themes.

Principle Findings. Health care providers perceived counselor certification it to be beneficial for

developing their skills and confidence in delivering CRA and CRAFT, but reported the

challenges of time constraints and competing tasks. Modification to the technical language, a

reduction in the number of sessions, and inclusion of group delivery, were suggested to make

to interventions more applicable for Aboriginal Australians.

Conclusions. Tailoring CRA and CRAFT was an iterative process involving ongoing consultations

and feedback from health care providers.

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Introduction

Aboriginal Australians experience a disproportionately high burden of alcohol-related harm,

compared to the general Australian population (Calabria et al. 2010; Vos et al. 2003).

Approaches that simultaneously target individuals and families at risk of alcohol-related harm

are likely to be acceptable to, and feasible for, delivery to Aboriginal Australians (Calabria et al.

2012), given that positive interaction with family members influences behavioral change in

Aboriginal Australians (Nagel & Thompson 2010), and family relationships are fundamental to

the cohesion and wellbeing of Indigenous communities (McLennan & Khavarpour 2004; Nagel

& Thompson 2010).

The Community Reinforcement Approach (CRA) (Meyers & Smith 1995) is an evidence-based

cognitive-behavioral intervention for problem drinkers (Miller & Wilbourne 2002). CRA aims to

reduce alcohol consumption by using social, recreational, family and vocational reinforcers to

motivate people towards making their non-drinking lifestyle more rewarding than drinking

alcohol. Community Reinforcement and Family Training (CRAFT) (Smith & Meyers 2007) is a

family-based intervention modelled on CRA and has been identified as an effective cognitive-

behavioral intervention with potential to be tailored, in collaboration with locally targeted

Aboriginal communities, for delivery in Aboriginal-specific health care settings (Calabria et al.

2012). CRAFT provides structured, personalised training and support to a family member of a

problem drinker. The aims of CRAFT are to teach family members how to effectively and safely

remove positive reinforcement for the problem drinker’s drinking behavior, increase positive

reinforcement for non-drinking behavior, and help to engage the problem drinker into

treatment. In addition, CRAFT aims to improve family members’ own social and emotional

wellbeing. CRA and CRAFT were both developed in the United States and include a structured

certification program for counselors. CRA and CRAFT have been found to be acceptable to

Aboriginal Australians in rural New South Wales (NSW) for delivery in their local community,

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when tailored to optimise their cultural appropriateness (Calabria et al. 2013). Although both

interventions have been successfully modified for other minority groups (Lopez Viets 2008;

Villarreal 2008; Meyers, Villanueva & Smith 2005; Miller, Meyers & Hiller-Sturmhofel 1999),

they have not been tailored for Aboriginal Australians.

This paper reports on a project that involved researchers working with health care services and

Aboriginal community members to tailor CRA and CRAFT for Aboriginal Australians in rural

NSW, Australia. The paper has three aims. Firstly, to describe the process of tailoring CRA and

CRAFT for delivery to Aboriginal Australians in rural New South Wales (NSW). Second, to

explore the perceptions of health care providers participating in the tailoring process. Third, to

explore the experiences of health care providers participating in CRA and CRAFT counselor

certification.

Methods

Ethics

Ethical approval for this study was provided by the Human Research Ethics Committee,

University of NSW, and the Aboriginal Health and Medical Research Council, Ethics Committee

of NSW. All interview participants provided informed consent (see Appendix C for consent

form).

Tailoring CRA and CRAFT

The process of tailoring CRA and CRAFT for Aboriginal Australians was an iterative process

comprising four key phases, as summarised in Figure 1. Each phase yielded data that informed

the tailoring process.

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1. Working group meetings with health care providers to adapt CRA and CRAFT for

routine delivery to Aboriginal Australians at risk of alcohol-related harm;

2. Survey of Aboriginal clients from participating health care services to examine their

perceptions of the acceptability of, and suggestions for tailoring, CRA and CRAFT for

delivery in their community (Calabria et al. 2013);

3. Certification of health care providers in CRA and CRAFT to develop their knowledge

and skills to deliver CRA and CRAFT in practice; and

4. Interviews with health care providers participating in CRA and CRAFT counselor

certification to explore their experiences of undertaking the counselor certification

programs and perceptions of the feasibility of CRA and CRAFT procedures for delivery

to Aboriginal Australians.

This paper presents results from Steps 1, 3 and 4. Results from Step 2 are reported elsewhere

(Calabria et al. 2013). This method of working in consultation with Aboriginal Australians and

health care providers to tailor CRA and CRAFT to be more acceptable to Aboriginal Australians

has been previously demonstrated to be feasible in other family-based research with different

Aboriginal Australians groups (Turner & Sanders 2007).

88

1. Working group meetings with health

care providers

3. Certification in intervention delivery

for health care providers

4. Interviews with health care providers

participating in certification

Modifications made to interventions

2. Consultation with Aboriginal clients of health care services

Figure 1. Process of tailoring the CRA and CRAFT interventions

The CRA and CRAFT counselor certification programs were delivered to health care providers

by Robert J. Meyers and Associates, internationally recognised trainers in CRA and CRAFT. To

complete CRA counselor certification, participants were required to attend a two day training

workshop, demonstrate competence in the 12 core CRA procedures through audio-taped

mock therapeutic sessions assessed by a certified CRA supervisor, and participate in a

minimum of four supervision meetings facilitated by a certified CRA supervisor. To complete

CRAFT counselor certification, participants were required to attend a two and a half day

training workshop, demonstrate competence in the 10 core CRAFT procedures through audio-

taped mock therapeutic sessions assessed by a certified CRAFT supervisor, and participate in a

minimum of four supervision meetings facilitated by a certified CRAFT supervisor. When

certification in one intervention approach (CRA or CRAFT) was achieved, certification in the

other approach only required attending the relevant training days and demonstrating

competence in four core procedures that differ between CRA and CRAFT. To be certified as a

89

CRA or CRAFT supervisor participants were required to complete the relevant counselor

certification, facilitate five relevant supervision sessions, and assess five relevant audio-taped

therapeutic sessions.

The tailoring process involved input and feedback from health care providers on: CRA and

CRAFT core procedures; printed resource materials used to work through core procedures with

clients (including worksheets for goals of counselling, Happiness Scale, Relationship Happiness

Scale, perfect relationship, problem solving, session checklist, and functional analysis); their

delivery of CRA and CRAFT; and Aboriginal-specific CRA and CRAFT manuals. Aboriginal-specific

CRA and CRAFT manuals were developed from CRA and CRAFT clinical practice manuals

(Meyers & Smith 1995; Smith & Meyers 2007). The tailored manuals summarized and

simplified the content of the original manuals and included scenarios relevant to Aboriginal

Australians, in order to better contextualize each intervention’s content and procedures. The

manuals were designed to be used for training health care providers in CRA and CRAFT and as

a resource to support them to deliver both interventions. Both manuals were written by a

researcher with more than 20 years of experience working in Aboriginal primary health care.

Input and feedback was also sought from health care providers regarding the most appropriate

and feasible research methods for examining the implementation of CRA and CRAFT in their

setting and evaluating its effectiveness among their client population using valid outcome

measures.


Study participants were 19 health care providers from a drug and alcohol treatment agency

and three health care providers from an Aboriginal Community Controlled Health Service

(ACCHS) in rural NSW, Australia (n = 22). All participants attended at least one working group

90

meeting and interviews were conducted with working group meeting participants who had

completed CRAFT counselor certification and CRA training days at the time of the interviews.

Table 1 summarises the professional role of participants, their level of participation in working

group meetings, and the current level of CRA and CRAFT qualifications they had attained.

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Table 1. Health care providers’ role and qualifications

ID Health care service role Meetings attended CRAFT qualification level CRA qualification level

101 Alcohol and drug counselor B, C, D, E Certified counselor Completed training days

102 Family drug and alcohol worker E, G, H Certified counselor Completed training days

103 Acting director of strategy and planning A, B, C, D, E, F, G, H Certified counselor and supervisor Certified CRA counselor and supervisor

104 Alcohol and drug counselor E, G, H Certified counselor Completed training days

105 Drug and alcohol mental health nurse E Certified counselor Completed training days

106 Family drug and alcohol worker D, E, G, H Certified counselor Completed training days

107 Program manager A, B, C, D, E, G, H Certified counselor and supervisor Certified counselor and supervisor

108 Tobacco cessation worker B None None

109 Family worker B, E Completed training days None

110 Chief executive officer B Completed training days None

111 Alcohol and drug counselor B, C, D Completed training days None

112 Alcohol and drug counselor C, H Completed training days None

113 Alcohol and drug counselor C, E, G, H Certified counselor Completed training days

114 Alcohol and drug counselor E Certified counselor Completed training days

115 Administration worker E None None

116 Family worker E Completed training days None

117 Alcohol and drug counselor G Certified counselor Certified counselor

118 Mental health outreach worker G None None

119 Mental health trainee H None None

120 Addiction specialist A, D, H None None

121 Business manager B None None

122 Chief executive officer B None None

Note. A = project development; B = research methodology; C = manual modification 1; D = manual modification 2; E = intervention resources and outcome survey

modifications; F = CRA and CRAFT training; G = recruitment 1; H = recruitment 2.

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Data collection

Working group meetings. Table 2 presents the overall focus of the eight working group meetings.

Working group meetings were an average of four and a half hours each (total of approximately 37

hours), were held at the participating rural drug and alcohol treatment agency or ACCHS, and were

chaired by researchers. The aims and content of each meeting was guided by a pre-planned

agenda. All working group members were given the opportunity to have input into the meeting

agenda. Detailed notes were recorded at each meeting and distributed to working group members

for their comment and validation. Notes were revised in response to working group members’

comments, and then examined for themes relating to health care providers perceptions of the

suitability of CRA and CRAFT and the type and level of tailoring required to enhance their

suitability for delivery to Aboriginal Australians. Themes identified from notes recorded at group

meetings A-F (see Table 2) informed the development of a semi-structured interview schedule to

be conducted with those participating in the CRA and CRAFT counselor certification program.

Table 2. Focus of working group meetings

Working group meeting Focus Date

A Project development November 2009

B Research methodology January 2010

C Manual modification 1 November 2010

D Manual modification 2 February 2011

E Intervention resources and outcome survey modifications November 2011

F CRA and CRAFT training May 2011

G Recruitment 1 September 2012

H Recruitment 2 February 2013

Semi structured individual interviews. Semi structured interviews were conducted with seven

health care providers who were recently certified in CRAFT and had completed the CRA training

days at the time of interviewing. All interview participants were from the drug and alcohol

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treatment agency. Interviews were conducted over two days in May 2012 in a private room at the

drug and alcohol treatment agency. The interview schedule included questions relating to health

care providers’ experiences of participating in CRA counselor training days and CRAFT counselor

certification, perceptions of the certification process, and perceptions of the suitability of CRA and

CRAFT for the treatment and management of Aboriginal people at risk of alcohol-related harm.

Interviews were conducted by a qualitative researcher with more than 20 years experience

working in Aboriginal primary health care and were an average of 39 minutes duration (range = 29

– 50 minutes). Interviews were audio-taped and recordings were transcribed verbatim for analysis.

Data analysis

Qualitative content analysis was used to systematically categorize text data into categories derived

inductively, and to summarize the data qualitatively (Forman & Damschroder 2008). Inductively

deriving the coding categories was appropriate given interviews were conducted with health care

providers about CRA and CRAFT used in an Aboriginal Australians health care setting for the first

time. The unit of analysis for the group meetings was the group and the unit of analysis for semi-

structured interview data was the individual. The qualitative content analysis followed three steps:

1) immersion resulted in listing memos (nine for working group meeting data and 23 for interview

data); 2) reduction summarized the memos into codes (five for working group meeting data:

CRAFT counselor certification, therapeutic issues, adaptability of CRA and CRAFT for Aboriginal

Australians, modifications to outcome measures, and possible referral pathways; and six for the

interview data: CRAFT counselor certification, CRA training, therapeutic issues, organisational

support, qualifications of therapists, and adaptability of CRA and CRAFT for Aboriginal Australians);

and 3) interpretation identified examples from specific working group meeting notes or from

individual health care provider interview transcripts relating to each code (Forman & Damschroder

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2008). Data pertaining to common codes across working group meeting notes and interview

transcripts were combined for interpretation (see Appendix D for qualitative data analysis).

Results

CRAFT counsellor certification

Health care providers initially perceived the CRAFT counselor certification process as daunting, but

having commenced the process perceived training days, audio-taped sessions for review and

feedback, and supervision sessions, as valuable for developing their skills and confidence in

delivering CRAFT.

(I) enjoyed the CRAFT training, I thought it was really good...(the CRAFT counselor

certification process has) been really, really valuable (health care provider 103).

As a component of CRAFT counselor certification, fortnightly supervision sessions were delivered

to health care providers via videoconferencing using Skype (Microsoft 2013) or ooVoo (LLC 2013).

These sessions were delivered regularly to enable the United States based CRA and CRAFT

certified supervisors to meet with health care providers undertaking CRAFT counselor certification

in Australia. The purpose of these meetings was for supervisors to redemonstrate CRAFT

procedures to health care providers and provide them with group level feedback on their

performance to date. Health care providers reported that supervision sessions were important for

developing their confidence and skills to deliver CRAFT procedures to the standard required to

complete the certification process, and for addressing their questions or concerns relating to

delivering CRAFT in practice.

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I think the Skype concept was definitely a recommendation that I would put in (health

care provider 102).

I thought that (supervision on Skype) was a very useful tool, rather than reading. I

think it was good because you could then ask questions directly (health care provider

103).

Although feedback about the supervision sessions was positive, health care providers reported

experiencing some technical difficulties when using the Internet-based programs for video

conferencing. Two health care providers are now certified CRAFT supervisors so ongoing CRAFT

supervision can be delivered face-to-face and will resolve these technical issues.

CRA training days

The two day CRA training was delivered after the two and a half day CRAFT training. Given that

some core CRA and CRAFT procedures are identical, there was some repetition. Nonetheless, the

CRA training days were well received by health care providers.

For those of us who had done CRAFT, we found the first day (of CRA training) a little

boring...but the second day, we did quite a few more exercises and...some group stuff

(health care provider 103).

...the CRA training...was fantastic... (health care provider 104).

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Therapeutic issues

There were three main challenges to health care providers completing CRAFT counselor

certification. First, staying motivated to complete all the audio-taped sessions in addition to their

usual workload was difficult for health care providers, all of whom identified this as a challenge.

...the negatives was the time and the pressure that (counselor certification) put on

you (health care provider 104).

...(the CRAFT counselor certification process) was challenging...fitting it in with work


This challenge was resolved by nominating an individual to co-ordinate the CRA and CRAFT

counselor certification process and by scheduling specific days for health care providers to

complete the required audio-taped sessions, without the distraction of competing work tasks.

The worst part was trying to get everyone motivated to do (the audio-taped sessions),

and actually co-ordinating them all to actually do them. So we set aside days...and

that worked well because everybody could just concentrate on that (health care

provider 107).

The second challenge of the CRAFT counselor certification process was initial reluctance by health

care providers to role play therapeutic procedures; however, the benefits of role plays for

consolidating and applying knowledge acquired from training days became apparent to health

care providers once they participated in role plays, and their reluctance appeared to diminish.

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...it was kind of hard to do (role plays) and feel natural about it...the more we did it,

the more you got used to that (health care provider 104).

...I am a lot more confident with using (CRAFT) now than I would have been if we

hadn’t have done the role plays before and just getting the feedback was good to

know this bit you did really well, this bit you probably need to work on (health care

provider 106).

The third challenge was the incongruence of some core procedures with health care providers’

previous counseling training. Concern was raised, in interviews and working group meetings,

about a process included in CRAFT that asks the family member of the drinker how they think their

relative feels about his/her own drinking and what they believe their relative is thinking when

he/she drinks. Health care providers generally perceived this question to be inappropriate.

I’d always learnt in counseling that you don’t get people to theorise or hypothesise

about how someone else feels (health care provider 103).

...trying to get an understanding of what does your loved one think right before he

drinks?, or what does he feel right before he drinks? I think that’s going to be pretty

hard for people and I guess how accurate that’s going to be is a bit of a concern I think


The role of organizational support

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Health care providers felt well supported by their organization and identified this support as

important. Support and encouragement from managers and other team members increased their

motivation to continue with CRA and CRAFT counselor certification.

It was really good to sort of work in a team that was doing it together... we sort of

kept pushing each other along and we needed to keep going with it, because we were

all doing it together (health care provider 104).

Qualifications of counselors

Although CRA and CRAFT have previously been delivered, in different settings, by individuals who

hold a university degree and have completed CRA and CRAFT counselor certification, health care

providers generally held the view that individuals with different levels of qualifications could

effectively deliver the interventions once certified in the approaches.

...so long as you had those people skills and sort of the willingness to sort of learn

something different, and then to apply it. Sometimes I think there’s some resistance

to apply it, maybe from some lack of confidence. But that’s - I think that’s more down

to an individual, rather than their level of knowledge and experience...sometimes

probably experience is a more useful thing than having the university education


One health care provider suggested that the manner in which certified counselors will deliver

intervention procedures is likely to be dependent upon their existing skills.

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I think that there’s quite a lot of high level practice required to implement CRAFT in

the way that it’s intended...I think people will vary in the way they implement the

procedures (health care provider 103).

Adaptability of CRA and CRAFT for Aboriginal Australians

Health care providers were generally of the view that CRA and CRAFT could successfully be

delivered to Aboriginal Australians if it tailored to their needs, preferences and literacy levels.

So I find using this kind of model, an American model, for an Indigenous population, it

doesn’t quite fit with me at the moment...there’s components within this training...I

think will work for indigenous people (health care provider 103).

In particular, changing the language used to suit the Aboriginal Australian population was

mentioned in both the interviews and the working group meetings. History, low literacy and

Aboriginal-specific use of the English language were commonly identified as reasons for changing

the language to make it more appropriate to Aboriginal people.

We’re going to have to modify (CRA and CRAFT) a bit for...Australia, for the

clients...just the wording and that sort of stuff...maybe use some pictures (health care

provider 107).

...you’re working with people who live in these worlds of chaos, you’ve really got to

look at the language so that everyday people in that country can relate to it. So I think

it really needs to be - an Australian version of it really needs to be looked at. The

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concepts are still the same but again, you need to look at it in a different way (health

care provider 102).

...(with Aboriginal people) you really need to look at what’s happened to them in the

past, how would you present this...I think it’s all doable with the Aboriginal

community, it’s just that the language might just need to be adapted a little bit to suit

them a bit better (health care provider 101).

Working group meetings and interviews were used to assess health care providers’ perceptions of

the CRA and CRAFT resources used to deliver the core procedures to clients. Overall the recourses

were believed to be useful, in particular, the Happiness Scale, that asks clients to rate health,

social, emotional and economic aspects of their life on a ten-point scale (1= completely unhappy,

10 = completely happy).

To maximize the likelihood of Aboriginal clients attending and completing the CRA and CRAFT

interventions it was suggested at working group meetings that less than eight sessions comprise

the Aboriginal-specific CRA and CRAFT interventions (the original United States based CRA and

CRAFT interventions are twelve sessions each), and that the interventions be available in a group

setting as well as to individuals, consistent with the usual model of care used by the health care

services.

Working group meetings with health care providers were used to gain feedback on early drafts of

the CRA and CRAFT manuals. Health care providers said that they wanted “...something to take

and something to refer to...not too detailed...more of a guideline” (working group meeting C).

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When the final versions of the manuals were made available to health care providers for comment

and review their feedback was generally positive.

...(the manual) made it a lot easier to understand what each component was (health care

provider 106).

...the scenarios out of the manual...were good (health care provider 107).

Outcome measures

In tailoring CRA and CRAFT for delivery to Aboriginal Australians, the research team proposed

reliable and valid clinical alcohol measures that could be used to identify Aboriginal people likely

to benefit from CRA and CRAFT and assess the effectiveness of CRA and CRAFT for reducing

alcohol-related harms among those identified to be at risk. These outcome measures not only had

to be valid and reliable for the identification and assessment of Aboriginal people at risk, but also

acceptable to those health care providers who were responsible for administering them to

Aboriginal people, and feasible for them to do so in the context of routine practice. Health care

providers deemed the package of outcome measures originally proposed by researchers as too

lengthy and time consuming to complete. The package of outcome measures originally proposed

aimed to measure drug and alcohol consumption, and social, emotional and physical wellbeing.

The package of outcome measures comprised demographic questions, the Emotional

Empowerment Scale (EES14) (Haswell et al. 2010), K-5 (Cunningham & Paradies 2012), Growth

Empowerment Measure (GEM) scenarios (Haswell et al. 2010), Alcohol Use Disorders

Identification Test (AUDIT) (Saunders et al. 1993), frequency of illicit drug use, Assessment of

Quality of Life - 6D (AQoL-6D) (Allen et al. 2013), time spent caring for a problem drinking relative

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(in CRAFT outcomes only), and health care service use questions. In response to health care

providers’ feedback, the package of outcome measures was revised to include demographics

questions, the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) (Humeniuk,

Ali & WHO ASSIST Phase II Study Group 2006), K-5 (Cunningham & Paradies 2012), GEM scenarios

(Haswell et al. 2010), and health care service use questions. The aims of the intervention

evaluation were not compromised by changes to the main outcome measures.

Recruitment options

Working group meetings G and H were used to identify and discuss recruitment options that

would have the potential to develop into ongoing referral pathways into CRA and CRAFT once

implemented into routine practice. Health care providers suggested a number of options including

through probation and parole, and other local health care services that do not currently provide

alcohol treatment services for Aboriginal Australians.

Discussion

CRA and CRAFT counselor certification involved a lengthy process that was positively reviewed by

health care providers at participating health care services. Initial challenges of time constraints

and reluctance to perform role plays were resolved by organising specific days to complete

certification measures and by ongoing organizational and peer support. Underfunding of

Aboriginal health care services (Allison, Rivers & Fottler 2004; Gray et al. 2010) often means that

employed health care providers have a large workload, and reiterates the importance of

organizations assigning a co-ordinator to ensure health care providers are motivated and given

time to participate in activities designed to improve their knowledge and skills to undertake their

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professional role. Underfunding also affects continuity of staff employment (Adams et al. 2005). In

this study, high staff turnover prompted the establishment of a locally based training and

certification program run by the two certified CRA and CRAFT supervisors. In addition to training

days and reviewing audio-taped sessions, these supervisors have developed a system whereby a

certified CRAFT counselor delivering CRA or CRAFT group sessions is assisted by a counselor in

training, rather than another certified counselor. This process ensures new staff have exposure to

the delivery of CRA and CRAFT in practice while they are undertaking the certification process, and

increases the number of staff available to deliver the interventions.

CRA and CRAFT counselor certification were completed in the original United States versions of

CRA and CRAFT. The CRA and CRAFT concepts and resources were thought to be applicable to

Aboriginal Australians, when tailored specifically for this population group. In particular, technical

language needed to be changed to words more regularly used by Aboriginal Australians. In

response, CRA and CRAFT resources have been modified to include more appropriate language,

and clear formatting in large font. For example, “Who is your loved one usually with when

drinking?” was changed to “Who is your relative usually with when drinking?” (see Appendix E for

tailored CRA and CRAFT intervention resources). Aboriginal-specific CRA and CRAFT manuals were

developed in consultation with group meeting attendees and identified as important resources for

health care providers to refer to. The modified examples of how to deliver the interventions,

included in the manuals, presented CRA and CRAFT in the Australian context which helped health

care providers to translate the United States CRA and CRAFT interventions into an Aboriginal

Australian based model of care. Changing the contextual focus has been the aim of other research

projects tailoring CRA or CRAFT for minority groups (Villarreal 2008; Miller, Meyers & Hiller-

Sturmhofel 1999). For example, alcohol dependent Native Americans were reconnected with their

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cultural spirituality through cultural practices, such as the talking circle, while participating in CRA

(Miller, Meyers & Hiller-Sturmhofel 1999). Other Aboriginal-specific interventions have also

focused on changing the context of an intervention, such as using story telling with parents and

children to improve behavioral problems and decrease parental psychological distress (Robinson

et al. 2012; Stock, Mares & Robinson 2012).

To ensure that CRA and CRAFT can be delivered in routine practice, Aboriginal-specific group

programs for CRA and CRAFT have been developed by CRAFT certified health care providers. These

group programs include the same content as the individual programs; however, the individual

programs are designed to use the core procedures in an order that is appropriate for each client

and the group programs presents the core procedures in a standardized order using a PowerPoint

presentation. Client workbook exercises are also included in the group programs. Clients attend six

group sessions and are given the opportunity to attend additional individual sessions if required.

Group delivery of intervention programs is appropriate for Aboriginal Australians and has been

successfully demonstrated by an Aboriginal-specific family-based intervention targeting parents

and children aimed at reducing Aboriginal disadvantage (Robinson et al. 2012; Stock, Mares &

Robinson 2012), and a healthy behaviours program promoted through an Aboriginal men’s group

(Bindon et al. 2009).

The variation in qualifications held by health care providers involved in CRA and CRAFT counselor

certification was not perceived to be a barrier for delivery but was believed to impact on how the

interventions would be delivered. This finding is consistent with studies exploring the optimum

mix of qualifications, experience and commitment required to effectively deliver CRAFT (Smith &

105

Meyers 2007). Two individuals have completed CRAFT supervisor certification, providing the

opportunity for ongoing local supervision of certified counselors to assist in intervention fidelity.

Limitations

The purpose of the interviews with health care providers was to explore their experiences of

participating in the process of tailoring CRA and CRAFT for Aboriginal Australians and undertaking

CRA and CRAFT counselor certification. Interviews were conducted with a small number of health

care providers from one drug and alcohol agency in NSW; however the sample represents 77%

(7/9) of all health care providers who had completed CRAFT certification and CRA training days at

the time of interviewing. Aboriginal Australian individuals were involved in the working group

meetings but none participated in the interviews, predominantly because they were no longer

working at the health care service, they were unable to participate in the certification process due

to competing priorities, or they appeared unwilling to participate due to fears and concerns they

would not be able to successfully complete to certification process. When health care services

who work with Aboriginal Australians become involved in research, changes are often required

within that service to accommodate the research process. Researchers must also make changes to

accommodate the delivery of interventions in a real world setting, as long as the changes do not

compromise the integrity and aims of the research.

The self-report nature of the data mean they are prone to bias, in particular social desirable

responding is likely. Social desirable responding is likely to have been minimized by anonymity

being assured to all participants, and interviews conducted in a private room (Hogan 2003).

Responses in working group meetings may have been biased by group think, but such data are

important for the modification of the CRA and CRAFT interventions.

106

Conclusion

CRA and CRAFT were tailored through an iterative process of which consultation between health

researchers and health care providers was a main component. The CRA and CRAFT counselor

certification process was perceived to be useful and informative to learn skills and build

confidence to deliver the interventions. The content of CRA and CRAFT were believed to be

appropriate for Aboriginal Australians; however core intervention procedures and methods for

their delivery required tailoring.

Acknowledgements

We would like to thank the health care providers for their participation in this project. Their

ongoing contributions have benefited this research greatly. This work was supported by a project

grant from the National Health and Medical Research Council and by the Australian Government

Department of Health and Ageing.

107

Paper 4

The acceptability to Aboriginal Australians of a family-based intervention to

reduce alcohol-related harms

Bianca Calabria1, Anton Clifford2,3, Anthony Shakeshaft1, Julaine Allan4,5, Donna Bliss6,

Christopher Dorn7,8

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales,

Australia

2. Institute of Urban Indigenous Health, Brisbane, Queensland, Australia

3. University of Queensland, Brisbane, Queensland, Australia

4. Lyndon Community, Orange, New South Wales, Australia

5. Centre for Inland Health, Charles Sturt University, Orange, New South Wales, Australia

6. Yoorana Gunya Family Violence Healing Centre Aboriginal Corporation, Forbes, New South Wales,

Australia

7. Hunter Medical Research Centre, University of Newcastle, Newcastle, New South Wales, Australia

8. Hunter Valley Research Foundation, Newcastle, New South Wales, Australia

Paper 4 has been published in Drug and Alcohol Review (Calabria et al. 2013).

108

Copyright Statement



Calabria, B, Clifford, A, Shakeshaft, A, Allan, J, Bliss, D & Doran, C 2013, 'The acceptability to

Aboriginal Australians of a family-based intervention to reduce alcohol-related harms', Drug and

Alcohol Review, vol. 32, no. 3, pp. 328-332.


109

Preamble

Paper 3 presented the experiences of health care providers participating in CRA and CRAFT

counsellor certification, and their suggestions for tailoring the interventions to be more applicable

for Indigenous Australians (Calabria et al. submitted-a). This consultation process resulted in

modifications made to intervention resources and method of delivery. Health care providers were

self-declared advocates for the delivery of CRA and CRAFT to Indigenous Australians after

completing CRAFT counsellor certification and, although all had experience working with

Indigenous Australians, none were of Indigenous origin. Consequently, their perceptions of the

appropriateness of CRA and CRAFT for Indigenous Australians needed to be complemented with

the views and preferences of Indigenous Australian people themselves. Paper 4 presents the

perceptions of the Indigenous clients of participating health care services of the acceptability of

CRA and CRAFT for delivery in their local community, and their suggestions for tailoring both

interventions (Calabria et al. 2013).

110

Abstract

Introduction: Cognitive-behavioural interventions that utilise familial and community reinforcers in

an individual’s environment are effective for reducing alcohol-related harms. Such interventions

have considerable potential to reduce the disproportionately high burden of alcohol-related harm

among Aboriginal Australians if they can be successfully tailored to their specific needs and

circumstances.

Aim: The overall aim of this paper is to describe the perceived acceptability of two cognitive-

behavioural interventions, the Community Reinforcement Approach (CRA) and Community

Reinforcement and Family Training (CRAFT), to a sample of Aboriginal people.

Design and Methods: Descriptive survey administered to 116 Aboriginal people recruited through

an Aboriginal Community Controlled Health Service and a community-based drug and alcohol

treatment agency in rural New South Wales, Australia.

Results: Participants perceived CRA and CRAFT to be highly acceptable for delivery in their local

Aboriginal community. Women were more likely than men to perceive CRAFT as highly acceptable.

Participants expressed a preference for counsellors to be someone they knew and trusted, and

who has experience working in their local community. CRA was deemed most acceptable for

delivery to individuals after alcohol withdrawal and CRAFT for people who want to help a

relative/friend start alcohol treatment. There was a preference for five or more detailed sessions.

Discussion and Conclusions: Findings of this study suggest that CRA and CRAFT are likely to be

acceptable for delivery to some rural Aboriginal Australians, and that there is potential to tailor

these interventions to specific communities.

111

Introduction

Aboriginal Australians experience a disproportionately high burden of alcohol-related harm

relative to the general Australian population (Calabria et al. 2010). Cognitive-behavioural

interventions that utilise positive familial and community reinforcers for low-risk drinking have

proven to be effective for reducing alcohol-related harms and improving the social and emotional

wellbeing of at-risk drinkers (Calabria et al. 2012; Miller & Wilbourne 2002). The influential role of

family and community factors in modifying health risk behaviours among Aboriginal people is

widely acknowledged (Australian Government Department of Health and Ageing 2007; Nagel &

Thompson 2010), and suggests that integrating these factors into cognitive-behavioural

interventions is likely to be effective for reducing alcohol-related harms among Aboriginal

Australians.

The Community Reinforcement Approach (CRA) uses social, familial and recreational positive

reinforcers to modify the behaviour of problem drinkers and is ranked among the most effective

cognitive-behavioural interventions (Meyers & Smith 1995; Miller & Wilbourne 2002). A family-

focused version of CRA, Community Reinforcement and Family Training (CRAFT) (Smith & Meyers

2007), is likely to be highly relevant to Aboriginal communities because it teaches practical skills to

family members of treatment resistant problem drinkers. Specifically, it aims to improve their own

health and well-being and assist them to encourage their problem drinking relative into treatment.

This study identifies the extent to which CRA and CRAFT are acceptable to Aboriginal Australians,

their preferences for how CRA and CRAFT ought to be delivered and a process of tailoring these

interventions for Aboriginal people.

112

Methods

Ethics

Ethics approval for the study was granted by the Human Research Ethics Committee, University of

New South Wales (NSW), the Ethics Committee of the Aboriginal Health and Medical Research

Council, NSW, and the board of the participating Aboriginal Community Controlled Health Service

(ACCHS). A steering committee, including Aboriginal health workers and researchers who live in

the participating communities, oversaw the over-arching project of which this study is a part.


Aboriginal participants who were over 18 years of age were recruited through existing groups

organised by one ACCHS and new clients of a community-based drug and alcohol treatment

agency in rural NSW, from July 2010 to June 2011, by researchers or Aboriginal health workers.

Participants were reimbursed $A40 to cover out-of-pocket travel expenses.

The survey

Survey development. The survey was adapted from the Treatment Acceptability Questionnaire

(Hunsley 1992) in consultation with health service staff, non-Aboriginal and Aboriginal researchers,

and Aboriginal clients of the participating drug and alcohol agency. The survey was initially

administered to four Aboriginal people, who were either receiving treatment or who had recently

completed treatment for alcohol use problems, to assess its appropriateness and

comprehensibility.

113

Overall acceptability of CRA and CRAFT was assessed using a 5-point Likert scale (1 = very bad, 5 =

very good) by asking ‘what do you think about CRA/CRAFT being delivered in your community?’

The acceptability of intervention delivery in rural settings was assessed as ‘okay’ or ‘not okay’.

Participants’ drinking risk status was measured, using the Alcohol Use Disorders Identification Test

(AUDIT) (Conigrave et al. 2012; Saunders et al. 1993; Saunders & Aasland 1987), to determine the

extent to which their drinking status was associated with their preferences for CRA and CRAFT

delivery.

Survey administration. Key information on CRA and CRAFT interventions was initially presented to

participants by a researcher or Aboriginal health worker, including the target client population, the

overall purpose, the therapeutic approach and the mode of delivery. Participants then self-

completed the survey (with literacy support available). Space was provided for participants to

write down additional comments. Survey completion was voluntary and responses confidential

(see Appendix F for survey advertising poster, Appendix G for participant study information sheet,

Appendix H for the survey, Appendix I for slides used by researchers or Aboriginal Health Workers

to standardise the presentation of intervention and survey information, and Appendix J for group

attendance record sheet).

Data analysis

Given few participants rated the acceptability of CRA and CRAFT as 1, 2 or 3, multinomial logistic

regression analyses were not appropriate. Consequently, ratings of the acceptability of CRA and

CRAFT were dichotomously coded as ‘bad’ (1 to 3) or ‘good’ (4 and 5). Predictors of ‘good’

[gender, drinking status (not/at risk or high risk drinker), family member drinking problem

(no/family member with a drinking problem), and health service (ACCHS/drug and alcohol

114

treatment agency)] were identified for CRA and for CRAFT, using separate binary logistic

regressions (Hosmer & Lemeshow 2000). Additional comments were examined for themes.

Results

The sample consisted of 116 Aboriginal Australians (n = 110) or non-Aboriginal Australians who

have an Aboriginal spouse and/or child (n = 6). Eleven individuals who completed the survey were

excluded because they were non-Aboriginal without an Aboriginal spouse or child. The response

rate was 94% (116/124). Table 1 shows the demographic characteristics of participants, 95% of

whom rated CRA as acceptable and 90% of whom rated CRAFT as acceptable. Women were more

likely than men to rate CRAFT as ‘good’ (odds ratio = 0.07, 95%CI = 0.01 – 0.56). Table 2 shows

that CRA was more acceptable as a post-withdrawal, rehabilitation or incarceration option and

CRAFT was more acceptable for people who want to help a problem-drinking relative/friend start

alcohol treatment. Preference was for a counsellor who was known and trusted, with experience

working in the local community.

Increased access to follow-up support (listed six times) and more interventions for young people

(listed seven times) were the most common additional comment by participants (see Appendix K

for additional methods and results not included in the published paper).

115

Table 1. Demographic characteristics of the sample (n = 116)

Characteristic n (%)

Gender Male 56 (48)

Female 59 (51)

Do not wish to answer 1 (1)

Age Range 18-72 years

Mean (SD) 39 (13) years

Health service

attended

Aboriginal Community Controlled Health Service 70 (61)

Community-based drug and alcohol treatment agency 19 (17)

Other services 25 (22)

Education No formal education 11 (10)

Primary school 17 (15)

High school (Year 10) 47 (42)

School certificate (Year 12) 8 (7)

Tertiary 21 (19)


Work Do not work 57 (51)

Full time 23 (21)

Part time 16 (14)

Casual 8 (7)


Drinking status Non-drinker 14 (13)

Low-risk drinker 32 (31)

At-risk drinker 11 (11)

High-risk drinker 47 (45)

Problem drinking

relative/friend

Yes 84 (76)

No 27 (24)

Worried about

problem drinking

relative/friend

1 (not worried at all) 1 (1)

2 2 (2)

3 17 (21)

4 18 (22)

5 (very worried) 44 (54)

116

Table 2. Preference for intervention delivery

n (%)

CRA CRAFT

Mode of delivery

Problem drinkers

After withdrawal 101 (90) --

Needing alcohol rehabilitation but not wanting it 80 (73) --

Waiting for alcohol rehabilitation 75 (68) --

After alcohol rehabilitation 88 (79) --

Referred from probation and parole 89 (80) --

People with a problem drinking relative/friend

In the alcohol withdrawal unit -- 101 (91)

Waiting for alcohol rehabilitation -- 98 (88)

Just finished alcohol rehabilitation -- 98 (89)

Referred from probation and parole -- 87 (79)

People who want to help a problem drinking

relative/friend to start alcohol treatment

--

104 (94)

Qualities thought most important in a counsellor delivering the interventions

Trust and familiarity

Someone I know and trust 76 (65) 67 (58)

Someone I know 2 (2) 6 (5)

Someone I trust 25 (22) 23 (20)

Does not matter 13 (11) 19 (17)

Experience working in the local community

Yes 80 (70) 76 (66)

No 3 (3) 4 (3)

Doesn’t matter 31 (27) 35 (30)

Aboriginality

An Aboriginal person 60 (53) 59 (52)

A non-Aboriginal person 1 (1) 1 (1)


Gender

A woman 17 (15) 18 (16)

A man 25 (23) 24 (21)


Number of sessions preferred for the interventions

1 to 2 sessions for very basic information 22 (20) 21 (18)

2 to 3 sessions for basic information 24 (21) 22 (19)

3 to 4 sessions for detailed information 16 (14) 18 (16)

5 or more sessions for very detailed information 50 (45) 54 (47)

CRA, Community Reinforcement Approach; CRAFT, Community Reinforcement Approach and Family Training

117

Discussion

Both CRA and CRAFT were highly acceptable to Aboriginal people. Counsellors who were known

and trusted, and delivery of five or more sessions, were preferred. CRA was deemed most

acceptable for individuals post alcohol withdrawal, and CRAFT for those wanting to help a

relative/friend start alcohol treatment. Improved follow-up support and more interventions for

young people were identified most frequently as important.

Recommended tailoring of each intervention

First, health workers who are known and trusted by the community should be available to deliver

CRA and CRAFT interventions. Health workers building trusting relationships with Aboriginal

community members has been shown to increase access to drug and alcohol services (Allan &

Campbell 2011) and, as a minimum, provides an alternative for those Aboriginal Australians whose

preference for a known counsellor outweighs their confidentiality concerns (Vicary & Westerman

2004). Second, five or more detailed sessions should be offered, which is consistent with findings

that the median number of CRAFT sessions attended is 4.7 (Miller, Meyers & Tonigan 1999). Third,

the tailored interventions should include follow-up support for participants, a need that has been

recognised through government consultations with Indigenous communities (Kurti et al. 2009).

Fourth, there is a need for the interventions to be available for young people, which reflects the

findings of a recent review that found no methodologically rigorous evaluations of interventions

targeting young people at high risk of alcohol-related harm that have a broader focus than the

individual (Calabria, Shakeshaft & Havard 2011). Given a CRA intervention designed specifically for

adolescents has been found to improve outcomes in non-Aboriginal groups (Dennis et al. 2004;

Slesnick et al. 2007), its acceptability to Aboriginal adolescents should be examined.

118

Limitations

A convenience sample was recruited, resulting in a sample of Aboriginal people likely to access

interventions through the participating health services and a high response rate (94%), as well as

under-representation of high-risk individuals resistant to treatment. Although 5% of the sample

perceived CRA as unacceptable and 10% perceived CRAFT as unacceptable, these relatively small

proportions suggest alternative interventions ought to be made available for them, rather than

further adaptation of CRA or CRAFT. Self-report data are prone to biases, even when bias is

minimised by using psychometrically validated tools (Hogan 2003). Repeating the survey after

trialling the intervention would provide further evidence about the acceptability of CRA and CRAFT

in practice.

Conclusion

The CRA and CRAFT interventions were acceptable to the majority of Aboriginal people recruited

through a rural ACCHS and a community-based drug and alcohol treatment agency, which has

both reinforced that a trial of their cost-effectiveness is warranted and helped tailor the specific

versions of the interventions to local Aboriginal communities.

Acknowledgements

We would like to thank the participating services (Lyndon Community and Yoorana Gunya Family

Violence Healing Centre Aboriginal Corporation), communities and their members for their

support and input, without which this research would not be possible. The CEOs of the

participating services have approved publication of these results in this format. We gratefully

acknowledge Barbara Toson for providing statistical advice. This work was supported by the

119

Australian Government Department of Health and Ageing and by a linkage grant from the

Australian Research Council.

120


Drug and Alcohol Review owns the copyright of this published paper. The points of clarification

have been added to provide additional information about the research for this thesis without

modifying the content of the published paper.

Table 1

The number of responses in Table 1 varies depending on missing data, with the exception of the

‘worried about problem drinking relative/friend’ which was only applicable to participants who

indicated that they had a problem drinking relative/friend.

Predictors of acceptability

Predictors of the acceptability of CRA and CRAFT were investigated using separate binary logistic

regressions (gender, drinking status, family member drinking problem, health service). The

analysis using gender had the only significant result. Non-significant results were not reported in

the paper.

121

Paper 5

Epidemiology of alcohol-related burden of disease among Indigenous

Australians

Bianca Calabria1, Christopher M Doran1, Theo Vos2, Anthony P Shakeshaft1,3 Wayne Hall4

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

2. School of Population Health, University of Queensland, Brisbane, Queensland, Australia

3. Sax Institute, University of Technology, Sydney, New South Wales, Australia

4. University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia

Paper 5 has been published in the Australian and New Zealand Journal of Public Health (Calabria et

al. 2010).

122

Copyright Statement



Calabria, B, Doran, CM, Vos, T, Shakeshaft, AP & Hall, W 2010, 'Epidemiology of alcohol-related

burden of disease among Indigenous Australians', Australian and New Zealand Journal of Public

Health, vol. 34, no. S1, pp. S47-S51.


123

Preamble

Paper 4 demonstrated the high level of perceived acceptability of CRA and CRAFT by Indigenous

clients of an Aboriginal Community Controlled Health Service and a rural drug and alcohol

treatment agency in New South Wales, for delivery in their community (Calabria et al. 2013).

Additionally, Paper 4 identified a perceived need among a sample of rural Indigenous Australians

for interventions to reduce alcohol-related harms among Indigenous young people. As a result,

Paper 5 examines alcohol-related harms experienced by Indigenous people by age and sex,

compared to the general population of Australia, in order to determine differences in the

magnitude and type of alcohol-related harms experienced by young Indigenous people versus

other age groups (Calabria et al. 2010).

124

Abstract

Objective: To compare the burden of alcohol-related harm and underlying factors of this harm, by

age and sex, for Indigenous and general population Australians.

Methods: Population attributable fractions are used to estimate the disability adjusted life years

(DALYs) for alcohol-related disease and injury. The DALYs were converted to rates per 1,000 by age

and sex for the Indigenous and general populations.

Results: Homicide and violence rates were much higher for Indigenous males: greatest population

difference was for 30-44 years, Indigenous rate 8.9 times higher. Rates of suicide were also

greater: the largest population difference was for 15-29 years, Indigenous rate 3.9 times higher.

Similarly for Indigenous females, homicide and violence rates were much higher: greatest

population difference was for 30-44 years, Indigenous rate 18.1 times higher. Rates of suicide

were also greater: the largest population difference was for 15-29 years, Indigenous rate 5.0 times

higher.

Conclusions: Alcohol consumption and associated harms are of great concern for Indigenous

Australians across all ages. Violent alcohol-related harms have been highlighted as a major

concern.

Implications: To reduce the disproportionate burden of alcohol-related harm experienced by

Indigenous Australians, targeted interventions should include the impact on families and

communities and not just the individual.

125

Introduction

Although the deleterious impact of alcohol on Indigenous Australians and their communities has

been extensively documented (Australian Bureau of Statistics & Australian Institute of Health and

Welfare 2005; Australian Bureau of Statistics & Australian Institute of Health and Welfare 2008;

Australian Department of Human Services and Health 1995; Australian Government Department

of Health and Ageing 2007; Chikritzhs, Fillmore & Stockwell 2009; Gray et al. 1997), obtaining

accurate estimates of the extent of harm across a range of health indicators (including death,

hospitalisations, quality of life and social costs) has been challenging. One approach to this task

has been to use Disability Adjusted Life Years (DALYs), a summary measure of health that

combines years of life lost (YLL) and years lived with disability (YLD) as a consequence of a disease

or injury.

Two reports using DALYs to describe the drug and alcohol-related burden of disease and injury in

Australia have recently been published: one for Australia generally (Begg et al. 2007); and one

specific to Indigenous Australians (Vos et al. 2003). In the general Australian population, alcohol is

responsible for 3.3%, and prevents 1% of the total disease burden, a net effect of 2.3%, equivalent

to 61,091 DALYs and 0.8% (1,084) of all deaths (Begg et al. 2007). For Indigenous Australians,

alcohol harm causes 6.2%, and prevents 0.8% of the total burden, a net effect of 5.4% (5,171) of

DALYs and 6.7% (192) of all deaths (Vos et al. 2003). The disproportionate burden of alcohol-

related harm experienced by Indigenous people results in an estimated life expectancy of 15 years

less, on average, than in the general population (Vos et al. 2003).

Using DALY estimates as the basis for developing, implementing and evaluating policies and

interventions will be critical given the clear lack of Indigenous alcohol intervention research to

126

date (Sanson-Fisher et al. 2006). Such policies and interventions, however, are likely to be more

effective if they are tailored to specific sub-populations and disease types (Sackett et al. 1996;

Ockene et al. 2007), rather than remaining restricted to broad-based, population-level

comparisons between general population and Indigenous Australians. This paper aims to compare

alcohol consumption DALYs for Indigenous and general population Australians by age and sex and

by disease or injury related to use.

Method

The methodology has been described in detail elsewhere (Begg et al. 2007; Vos et al. 2003; 2008);

a summary follows. The population attributable fraction (PAF), representing the expected

proportional reduction in mortality if alcohol exposure were reduced to an alternative

(counterfactual) distribution, was calculated before determining the number of attributed deaths.

The PAF uses the exposure level, actual population distribution of the exposure; counterfactual

(alternative) population distribution of the exposure, relative risk of mortality at exposure level

and maximum exposure level (see equations 1A for continuous exposures and 1B for categorical

exposures).

127

Equation 1A

∫ ( ) ( )

∫ ( ) ( )

∫ ( ) ( )

x = exposure level

P(x) = actual population distribution of exposure

P’(x) = counterfactual (alternative) population distribution of exposure

RR(x) = relative risk of mortality at exposure level x

m = maximum exposure level

Equation 1B

∑ ∑

∑

n = number of exposure categories

Pi = proportion of population currently in the ith

exposure category

P’i = proportion of population in the ith

exposure category in the counterfactual (alternative) scenario

RRi = relative risk of disease-specific mortality for the ith

exposure category

In order to estimate the number of alcohol-attributable person deaths in the population, in part

(e.g. accidents) or whole (e.g. alcoholic liver cirrhosis), the population distributions of alcohol

exposure were based on individual-level consumption data (Ridolfo & Stevenson 2001; Begg et al.

2007; English et al. 1995). Alcohol consumption data, for the general Australian population, were

taken from the National Health Survey (NHS 2001) (Australian Bureau of Statistics 2001). For the

Indigenous population the prevalence of alcohol consumption was derived from the Australian

128

Bureau of Statistics National Aboriginal and Torres Strait Islander Health Survey (NATSIHS) 2004-05

(Australian Bureau of Statistics 2006). Prevalence of alcohol consumption was categorised into the

four levels used in English and colleagues’ analysis of the risks of alcohol consumption (English et

al. 1995), in accordance with the NHMRC’s recommendations on alcohol consumption (National

Health and Medical Research Council 1992). The population distributions of alcohol exposure for

each level of alcohol intake were estimated by age and sex for both Indigenous and general

population Australians.

Relative risks and PAFs from Ridolfo and Stevenson (Ridolfo & Stevenson 2001) were used for

conditions for which there is evidence of causation by alcohol consumption. Included in these

estimates are harms, i.e., injury or diseases, that are causally related and completely attributed to

alcohol exposure as well as related harms that are causally but not solely attributed to alcohol

exposure (contributing factors) (Rehm et al. 2004).

The following diseases and injuries were included: ischemic heart disease; other cardiovascular

disease (CVD) (including stroke, hypertensive heart disease and inflammatory heart disease);

cancer; road traffic accidents; homicide and violence; suicide (including self-inflicted injuries);

alcohol use disorders (including dependence, harmful use, alcoholic cirrhosis); and other (including

fire, burns and scalds, gallbladder and bile duct disease, surgical and medical misadventure,

striking and crushing accidents, poisoning, cutting and piercing accidents, sports injuries, other

transport accidents, natural and environmental factors, machinery accidents, suffocation and

foreign bodies, drowning, pancreatitis, and falls).

129

Age standardisation was applied to DALYs to account for the variation in age structure between

Indigenous and the general population, resulting in comparable age specific estimates. The DALYs

for alcohol-related harm and contributing factors were converted to rates per 1,000 by age and

sex for the Indigenous and general populations.

Results

Alcohol-related burden of harm

Rates of alcohol-related harm among Indigenous males are three times higher than in the general

Australian population: rates were more than twice as high for Indigenous males aged 0-29 years

and more than three times higher thereafter. Rates for Indigenous females were seven times

higher than general population females, consistently more than five times higher from age 15-59

years (see Table 1).

Contributing factors to alcohol injury and disease

Males. In terms of underlying alcohol-related disease and injury, rates of DALYs for Indigenous

males were higher than general population males across all age groups (see Figure 1, Table 1).

Road traffic accidents were the main contributing factor for alcohol-related harm in Indigenous

males aged 0-14 years (2.3 times higher). Homicide and violence rates were much higher for

Indigenous males: 6.1 times higher for 15-29 year olds; 8.9 times higher for 30-44 year olds; 7.5

times higher for 45-59 year olds; and 5.0 times higher for 60 years or more. Rates of suicide were

also greater for Indigenous males: the largest difference between populations was for 15-29 year

olds with the Indigenous rate 3.9 times higher. Alcohol use disorders made a larger contribution in

later years of life with rates 5.8 times higher for 45-59 year olds and 4.8 times higher for

130

Indigenous males aged 60 years or more. On the positive side, the protective effects of ischemic

heart disease were higher in Indigenous males compared to the general population: 6.6 times

higher for 15-29 year olds; 8.3 times higher for 30-44 year olds; 4.0 times higher for 45-59 year

olds; and 2.0 times higher for 60 years or more (see Table 1).

Females. Among Indigenous females, rates of DALYs were higher than general population females

(with the exception of similar rates for both groups for cancer) across all age groups (see Figure 2,

Table 1). Similarly to Indigenous males, road traffic accidents were the main contributor to

alcohol-related harm for Indigenous females aged 0-14 years (2.4 times higher). Homicide and

violence rates were much higher for Indigenous females: 13.9 times higher for 15-29 year olds;

18.1 times higher for 30-44 year olds; 6.0 times higher for 45-59 year olds; and 20.7 times higher

for 60 years of more. Rates of suicide were also greater for Indigenous females: the largest

difference between populations was for 15-29 year olds with the Indigenous rate 5.0 times higher.

Alcohol use disorders made a larger contribution later in life with rates 10.9 times higher for 45-59

year olds and 9.9 times higher for Indigenous females aged 60 years or more.

131

Table 1. Rates (DALYs per 1,000) of alcohol-related disease and injury, Australia

Age (years) Age (years)

0-14 15-29 30-44 45-59 60+ Total 0-14 15-29 30-44 45-59 60+ Total

Indigenous population General population

Males

Ischemic heart disease 0.00 -0.33 -4.05 -8.57 -12.24 -2.26 0.00 -0.05 -0.49 -2.14 -6.13 -1.52

Other CVD 0.00 0.38 1.42 2.84 7.64 0.98 0.00 0.19 0.20 0.42 1.29 0.37

Cancer 0.00 0.03 1.41 6.79 12.11 1.48 0.00 0.04 0.33 1.77 3.02 0.91

Road traffic accidents 0.71 4.98 4.87 2.22 0.43 2.81 0.31 2.41 1.42 0.45 0.13 1.00

Homicide and violence 0.00 3.70 4.28 1.42 0.30 1.98 0.00 0.61 0.48 0.19 0.06 0.29

Suicide 0.00 5.51 6.68 1.56 1.17 2.98 0.00 1.42 1.90 1.17 0.46 1.03

Alcohol use disorders 0.00 3.99 12.11 24.86 15.09 6.59 0.00 3.36 3.10 4.32 3.13 2.76

Other 0.16 1.16 1.81 1.61 1.51 0.95 0.05 0.53 0.50 0.44 0.69 0.43

Total males 0.88 19.41 28.53 32.74 26.01 15.52 0.36 8.54 7.44 6.63 2.65 5.29

Females

Ischemic heart disease 0.00 -0.14 -1.09 -2.82 -5.26 -0.83 0.00 -0.01 -0.09 -0.42 -2.52 -0.57

Other CVD 0.00 0.18 0.05 -0.85 -2.44 -0.16 0.02 -0.06 -0.12 -0.55 -2.13 -0.53

Cancer 0.00 0.06 0.64 1.97 4.95 0.61 0.00 0.02 0.39 1.30 1.59 0.63

Road traffic accidents 0.17 0.84 1.40 0.39 0.00 0.62 0.07 0.27 0.18 0.06 0.00 0.12

Homicide and violence 0.00 3.20 3.07 0.36 0.62 1.56 0.00 0.23 0.17 0.06 0.03 0.10

Suicide 0.00 0.99 1.30 0.29 0.00 0.57 0.00 0.20 0.40 0.29 0.09 0.20

Alcohol use disorders 0.00 2.00 8.04 10.04 6.16 3.60 0.00 0.70 1.13 0.92 0.62 0.69

Other 0.09 0.19 0.52 0.66 1.40 0.33 0.03 0.11 0.14 0.14 0.86 0.24

Total females 0.25 7.32 13.92 10.03 5.43 6.31 0.12 1.46 2.20 1.79 -1.49 0.89

Notes: Other CVD = stroke, hypertensive heart disease, inflammatory heart disease; suicide = including self-inflicted injuries; alcohol use disorders = including

dependence, harmful use, alcoholic cirrhosis; other = fire, burns and scalds, gallbladder and bile duct disease, surgical and medical misadventure, striking and

crushing accidents, poisoning, cutting and piercing accidents, sports injuries, other transport accidents, natural and environmental factors, machinery accidents,

suffocation and foreign bodies, drowning, pancreatitis, falls.

132

Figure 1: Alcohol-related disease and injury by sex: males

Figure 2: : Alcohol-related disease and injury by sex: females

-6 -4 -2 0 2 4 6 8

Ischemic heart disease

Other CVD

Cancer

Road traffic accidents

Homicide and violence

Suicide

Alcohol use disorder

Other

Rates per 1000

Generalpopulation

Indigenouspopulation

-6 -4 -2 0 2 4 6 8

Ischemic heart disease

Other CVD

Cancer

Road traffic accidents

Homicide and violence

Suicide

Alcohol use disorder

Other

Rates per 1000

Generalpopulation

Indigenouspopulation

133

Discussion

Previous analyses have shown alcohol DALYs are much higher in Indigenous, compared to

general population Australians (Begg et al. 2007; Vos et al. 2003). This study shows that rates

of alcohol disease burden are consistently higher for Indigenous people across all age groups.

It also shows the specific disease or conditions that cause the most alcohol harm, common to

both males and females, are homicide and violence, suicide, alcohol use disorders, and road

traffic accidents.

The elevated contribution of alcohol to male and female homicide and violence confirms

findings from a recent Australian Government report that highlights alcohol as an important

factor for violence in Indigenous communities (Wundersitz 2010). Homicide and violence affect

not only drinkers but may cause harm to people who do not drink alcohol and since these

cases are not easily identified by data systems, our results are likely to be underestimates. The

extent of underestimation is likely to be greater for females, relative to males, given females

are more often victims of violence and homicide (People 2005).

Other alcohol-related harms were also consistently higher for Indigenous than general

population Australians: rates of suicide were especially elevated among Indigenous males and

females under the age of 44 years. The most commonly reported method of suicide for

Indigenous males was hanging, followed by death by firearms (Hunter et al. 1999). Violent

methods of suicide used by Indigenous males are similar to those reported by males in the

Australian general population (Denning et al. 2000). Indigenous female methods of suicide are

also notably violent, with hanging most commonly reported (Hunter et al. 1999), rather than

drug overdose in general population females (Denning et al. 2000).

134

Limitations

There is an urgent need to improve the evidence base for alcohol policy in Australia

(Shakeshaft, Doran & Byrnes 2009). Although this research is based on epidemiological studies

that apply an accepted methodology, the underlying data used to calculate alcohol-related

harm are drawn from a range of sources from varying quality including: specific Indigenous and

general population alcohol prevalence data; relative risks from international literature for

chronic diseases; Australian general population data on alcohol-related injuries; and variety of

other sources that were predominantly Australian. Self-reported consumption data used are

prone to biases (Hogan 2003): however, this method of estimating alcohol-attributed deaths

has been commonly used (Ridolfo & Stevenson 2001; English et al. 1995). Although estimates

of alcohol disease and injury include a wide range of conditions, they are likely to be an

underestimate of the true proportion of alcohol-related harm because: 1) they exclude

alcohol-related injuries experienced by individuals who have not consumed alcohol, primarily

because there are no valid and reliable estimates of the extent of alcohol harm experienced by

non-drinking victims; and 2) it is likely that not all perpetrators who have consumed alcohol

are identified. Few direct data sources for Indigenous estimates were found so relativities

found in proxy measurements were largely used (Begg et al. 2007; Vos et al. 2003). Further,

the data from the Australia Burden of Disease and Injury study (Begg et al. 2007) did not

explicitly separate Indigenous from non-Indigenous populations. The substantial alcohol-

related harm reported in these studies reinforces the need for improved data collection.

Policy implications

Information is available on potential strategies to reduce alcohol harm, although most of the

recent studies tend to focus on strategies to curb alcohol-misuse in the general population,

such as changes to the taxation of alcoholic beverages (Cobiac et al. 2009; Byrnes et al. 2010).

The cost-effective population-wide approaches to reducing alcohol harm would be improved

135

by implementing complementary interventions tailored specifically to high-risk sub-

populations or diseases and conditions (Doran et al. 2010). The analyses in this paper suggest

interventions that focus on reducing homicide and violence in Indigenous males and females,

and with specific attention to lowering rates of suicide for Indigenous males and decreasing

the number of Indigenous females who have an alcohol use disorder, are most likely to have

the biggest impact in reducing alcohol-related harm for Indigenous Australians and their

communities (Wundersitz 2010).

Indigenous Australians have a unique pattern of alcohol-related disease and harm that justifies

implementation of specific interventions for this population. Implementing more than one

intervention strategy would increase the likelihood of significantly reducing alcohol-related

problems (Cobiac et al. 2009; Doran & Shakeshaft 2008). Given the disproportionately high

rates of alcohol use disorders, homicide and violence, and suicide, it may be that interventions

specific to factors critical to the functioning of Indigenous communities and individuals would

be highly cost-effective. Positive interaction with family, for example, has been identified by

Indigenous Australians as the most important characteristic to facilitate behaviour change

generally (Nagel & Thompson 2010) and the major reason for reducing or ceasing alcohol use

specifically (Hunter, Hall & Spargo 1991; Nagel & Thompson 2010). This highlights the potential

importance of developing intervention strategies that include families, as well as communities

and individuals. It is critical, however, that any intervention is developed and implemented in

consultation with Indigenous community members, families and individuals, to ensure they are

culturally acceptable, reflecting the knowledge base and world view of Indigenous Australians

(Dixon et al. 2007; Vos et al. 2003).

In addition to social harms, there is clearly a need for more effective interventions to reduce

deaths and injuries associated with traffic accidents, especially among young people. Despite

136

the effectiveness of random breath testing (Cobiac et al. 2009) road traffic accidents are a

substantial problem for Indigenous and general population Australians, except females 60

years or more. A recent analysis relevant to the Australian population generally, indicated that

the most cost-effective strategies for reducing alcohol-related road deaths among young

Australians are likely to be a zero-tolerance policy for alcohol and driving until the age of 22

years (Hall et al. 2010).

Conclusions

Indigenous males had a higher alcohol-related burden of disease than general population

males attributable to all contributing factors. Indigenous males also had a higher protective

effect of ischemic heart disease. Key problem areas for alcohol-related harm among

Indigenous Australian males were: homicide and violence, suicide and road traffic accidents.

Indigenous females had a higher alcohol-related burden of disease than general population

females with the exception of similar rates for cancer across groups. Although Indigenous

females had a higher protective effect of ischemic heart disease, general population females

had a higher protective effect for other CVD. Key problem areas for alcohol-related harm

among Indigenous females were: homicide and violence, alcohol use disorders and road traffic

accidents.

An informed policy response first requires a detailed characterisation of the contributions that

alcohol use makes to disease burden by age, sex and Indigenous status as we present in this

paper. It also requires methodologically rigorous evaluation of culturally sensitive

interventions to reduce Indigenous alcohol-related harm and should, in the Indigenous

context, include the impact on families and communities and not just the individual.

137

Paper 6

A systematic and methodological review of interventions for young

people experiencing alcohol-related harm

Bianca Calabria1, Anthony P. Shakeshaft1, Alys Havard1

1. National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia

Paper 6 has been published in Addiction (Calabria, Shakeshaft & Havard 2011).

138

Copyright Statement



Calabria, B, Shakeshaft, AP & Havard, A 2011, 'A systematic and methodological review of

interventions for young people experiencing alcohol-related harm', Addiction, vol. 106, no. 8,

pp. 1406-1418.


139

Preamble

Paper 5 demonstrated that Indigenous people have a unique pattern of alcohol-related disease

and harm and young Indigenous people experience alcohol-related harms differently to older

Indigenous people. Most notably, road traffic accidents and violent alcohol-related harms

were of concern for young Indigenous Australians, compared to alcohol use disorders and

violent alcohol-related harms among older Indigenous Australians. Paper 6 investigates which

interventions are available for, and offer the greatest potential to reduce harms among, young

people at high risk of alcohol-related harm. The systematic and methodological review focuses

on interventions delivered outside of educational settings because school-based interventions

are usually prevention focused and are, therefore, unlikely to impact on high-risk young

people, predominately because they attend school infrequently (Best et al. 2006). As with

Paper 1 (Calabria et al. 2012), Paper 6 (Calabria, Shakeshaft & Havard 2011) does not focus

specifically on Indigenous people, because of the lack of published evaluations of interventions

specifically targeting Indigenous young people at high risk of alcohol-related harm (Gray et al.

2010). The identified mainstream interventions could be tailored for young Indigenous

Australians, if they are found to be acceptable to this group.

140

Abstract

Aims: This review identified published studies evaluating interventions delivered outside of

educational settings, designed for young people with existing alcohol use problems, or who

participate in behaviour that places them at high risk of alcohol-related harm, critiqued their

methodology and identified future opportunities for new interventions.

Methods: A systematic search of the peer-reviewed literature interrogated ten electronic

databases using specific search strings, limited to 2005-09. No additional studies were found

by a librarian searching other collections and clearing-houses, or by hand-searching review

paper reference lists. The 1697 articles identified were reviewed against criteria from the

Dictionary for the Effective Public Health Practice Project Quality Assessment Tool for

Quantitative Studies.

Results: The methodological quality of existing studies is variable, and needs to be both more

rigorous and more consistent. Particular problems include the lack of blinding outcome

assessors, a reliance solely on self-report measures, highly variable consent and follow-up

rates, infrequent use of intention-to-treat analyses and the absence of any economic or cost

analyses. The range of interventions evaluated is currently limited to individually focused

approaches, almost exclusively implemented in the United States.

Conclusions: There is a great need for more intervention trials for young people at high risk of

experiencing alcohol-related harm that are both methodologically rigorous and have a broader

community focus, to complement the psychological interventions that currently dominate the

relevant literature. Such trials would improve outcomes for high-risk young people themselves

and would improve the evidence base, both in their own right and by facilitating future meta-

analyses.

141

Introduction

Alcohol consumption guidelines recommend that healthy females and males limit their alcohol

consumption to minimise their risk of alcohol-related harm (National Health and Medical

Research Council 2009; U.S. Department of Health and Human Services & U.S. Department of

Agriculture 2005). Current Australian guidelines, for example, recommend that both males and

females drink no more than two standard drinks per day (a standard drink is defined as 10 g of

alcohol) to minimise the likelihood of experiencing harms associated with risky drinking over

the longer term, including dependence, depression and cancer (Fergusson, Boden & Horwood

2009; Seitz & Cho 2009; Calabria et al. 2010; National Health and Medical Research Council

2009), and limiting consumption on one occasion to no more than four standard drinks (both

males and females), to minimize the risk of short-term alcohol-related harms (National Health

and Medical Research Council 2009), such as driving under the influence of alcohol (DUI),

accidents, injuries, violence and crime (Begg & Gulliver 2008; Cherpitel & Ye 2008; Calabria et

al. 2010). These deleterious outcomes (both short- and long-term) impose substantial costs on

both the individuals experiencing the harm (Collins & Lapsley 2008; Petrie et al. 2008) and

their communities (Rehm et al. 2009; Petrie et al. 2008; Czech et al. 2010; Breen et al. 2011b).

A greater proportion of young people, relative to other age groups, consume alcohol at a level

that places them at increased risk of harm in the short and long term (Australian Institute of

Health and Welfare 2008b). In the United States, for example, consuming five or more

standard alcoholic drinks (a standard drink is defined as 14 g of alcohol) on the same occasion

is reported by over 40% of young people aged 21-29 years (21 is the minimum legal drinking

age in the United States), compared to fewer than 30% for older age groups, a proportion that

decreases with increasing age. A substantial proportion of young people under the United

States’ minimum legal drinking age also report alcohol use at this level: over 30% of 18-20-

142

year-olds; almost 20% of 16-17-year-olds; approximately 5% of 14-15-year-olds; and about 1%

of 12-13-year-olds (Substance Abuse and Mental Health Services Administration 2009).

Attempts to reduce alcohol harm experienced by young people have largely focused on school-

based education and prevention interventions for students and/or parents (Wood et al. 2006;

Foxcroft et al. 2002). It is likely school-based interventions are routinely implemented because

schools provide access to a large number of young people across a broad geographic area and

interventions can be easily incorporated into diverse curricula. The evidence for their

effectiveness in modifying drinking behaviour (as opposed to increasing awareness or

knowledge) is limited (Vogl et al. 2009; McBride et al. 2004; Wood et al. 2006). Harm

minimization approaches have been found to be effective in increasing knowledge and

attitudes related to safe drinking choices (Vogl et al. 2009; McBride et al. 2004) and decreasing

alcohol-related harms experienced by the drinking individual, but not harms from other

peoples’ alcohol use (McBride et al. 2004). Despite this, broad-based educational strategies

may be justified on the basis that they are relatively inexpensive to implement and could

achieve small benefits for individuals across large population groups (Newton et al. 2010).

These broad-based educational interventions, however, generally aim to prevent alcohol use

or misuse among the general student population and are unlikely to impact significantly on the

minority of young people who currently experience substantial alcohol-related harm, primarily

because they do not regularly attend school (Best et al. 2006).

Interventions delivered outside of educational settings that are designed for young people

who are experiencing alcohol-related harm or are participating in high-risk drinking behaviour,

are likely to be highly cost-beneficial even if they are expensive to implement, if they can

achieve relatively modest improvements in personal and employment trajectories over a life-

time (Cohen 1998; Pacileo & Fattore 2009; McGorry et al. 2007) Despite reviews of alcohol

143

interventions for young people being previously published (Tripodi et al. 2010; Fletcher, Bonell

& Hargreaves 2008; Gates et al. 2006; Smit et al. 2008; Spoth, Greenberg & Turrisi 2008;

Toumbourou et al. 2007; Velleman, Templeton & Copello 2005; Coombes et al. 2008; Williams

& Chang 2000), none have recently focused on youth who are experiencing alcohol-related

harm or participating in behaviour that increases their risk of harm.

This systematic review aims to: (1) identify published studies evaluating interventions

delivered outside formal educational settings, designed for young people with existing alcohol

use problems or who participate in behaviour that places them at high risk of alcohol-related

harm; (2) describe and critique their methodology; and (3) identify future opportunities for

methodologically adequate intervention studies.

Methods

Sample

Rather than specify an arbitrary age range a priori, which may have resulted in good-quality

intervention studies failing to be detected, the search strategy used the more general search

term ‘youth’. Studies were included for review if the young people met any of four alcohol-

related criteria. First, a diagnosis of alcohol dependence or abuse according to the Diagnostic

and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric

Association 1994); secondly, at-risk alcohol use as assessed by a formal screening instrument,

such as the Alcohol Use Disorders Identification Test (AUDIT) (Saunders et al. 1993); thirdly,

referral for treatment for an alcohol use problem; fourthly, engagement in high-risk alcohol-

related behaviour, such as drinking above recommended guidelines or DUI.

144

Search strategy

Figure 1 summarizes the databases searched, the search terms used, the exclusion criteria and

classification of included studies (see Appendix L for search strings).

Consistent with methods detailed in the Cochrane Collaboration Handbook on Systematic

Reviews of Health Promotion and Public Health Interventions (Jackson 2007), and with previous

reviews (Shakeshaft, Bowman & Sanson-Fisher 1997; Havard, Shakeshaft & Sanson-Fisher

2008; Webb et al. 2009; Wood et al. 2006), the search strategy comprised three steps. First, 10

electronic databases were searched: ACP Journal Club; CCTR; CDSR; Project Cork; DARE;

EMBASE; ERIC; MEDLINE; PsycINFO; and Web of Science. Electronic databases were searched

individually so that database-specific search strings could be used to identify relevant articles

more effectively, compared to using generic search terms for searching all databases

simultaneously. CDSR, ACP Journal Club and DARE were the exception; they were searched

simultaneously so that CDSR could be accessed via the OvidSP platform. The search terms

‘youth’ (‘basic’ and ‘advanced terms’), ‘alcohol’, ‘alcohol abuse/dependence’, ‘intervention’

(‘basic’ and ‘advanced terms’), ‘risk’ and ‘disruptive’ were integrated into database-specific

search strings (including subheadings, MESH terms, EMTREE terms and explode terms).

Combinations of these search strings were tested and resultant data coverage was reviewed.

The most parsimonious combination used the search terms ‘youth’ (‘basic terms’), ‘alcohol’,

‘intervention’ (‘basic terms’) and ‘risk’. To be as inclusive as possible, no specific age range was

defined by the search terms. The combined searches of all databases (CDSR, ACP Journal Club,

DARE, CCTR, EMBASE, Medline, PSYCInfo, ERIC, Project Cork and Web of Science) located 2243

references. Duplicates were electronically deleted leaving 1697 references for classification.

145

Figure 1. Flowchart indicating search strategy and classification of articles

Database search: CDSR, ACP Journal Club, DARE, CCTR, EMBASE, Medline, PsycINFO, ERIC, Project Cork and Web of Science

Separate search for each database using database specific search strings (with the acceptation of CDSR, ACP Journal Club

and DARE that were searched simultaneously)

Keywords used:

a. Young people (basic terms)

b. Alcohol

c. Intervention (basic terms)

d. Risk

Limited to 2005-2009

2243 articles were identified with automatic/electronic removal of 546 duplicates

Manual search of 1697 citations/abstracts to

exclude articles that do not have a primary focus on

alcohol

Removal of 55 articles that did not present raw data

570 articles categorised by type of publication

Measurement

26 (5%)

Descriptive

333 (58%)

Intervention

148 (26%)

Dissemination/ adoption studies

11 (2%)

Reviews

52 (9%)

EXCLUDED

Primary focus not alcohol 705 health/mental health (522) smoking/tobacco (44) illicit drugs (96) sexual behaviour (36) other (7) Not peer reviewed 363 Animal study 4

Total 1072

EXCLUDED

Not young people dependent on alcohol or at high-risk of experiencing alcohol-related harm (including educational settings)

137

Not English 2

Total 139

9 intervention studies for youth experiencing alcohol

related harm included

Methodological Review

146

Secondly, an experienced librarian conducted searches to identify additional studies that the

original search may have missed. DRUG, APAIS, Health, DrugInfo Clearinghouse, SafetyLit and

the National Drug and Alcohol Research Centre library collection were searched using search

terms ‘young people’ or ‘youth’, ‘alcohol’ and ‘intervention’. This additional search did not

locate any relevant articles that had not already been identified.

Finally, the reference lists of all review articles, identified by the electronic database search

and focused on alcohol interventions for youth, were hand-searched for any relevant studies

that had not been identified. No relevant studies were identified during this process.

All searches were limited to 2005-09 for two reasons. First, since broad search terms were

used to maximize the range of intervention types identified, the number of years searched was

limited to 5 to ensure a realistic number of studies could be categorized and to ensure that a

realistic number of intervention studies could be critiqued; and secondly, to optimize the

likelihood that the most recent intervention studies would be included, on the assumption that

the interventions being evaluated would represent current best-evidence practice.

Classification of studies

The titles and abstracts (if the title did not contain enough descriptive information to classify

the article) of the 1697 identified references were classified in a three-step process.

Step 1: applying exclusion criteria. Papers were excluded if: (i) they did not focus on alcohol

use, alcohol abuse, alcohol dependence or alcohol problems (n = 705); (ii) they were not peer-

reviewed (n = 363), including a number of books identified by Project Cork; or (iii) they were an

animal study (n = 4). A total of 1072 papers were excluded.

147

Step 2: study type. Fifty-five papers were removed because they did not present raw data

(non-data based papers and comments). The 570 remaining papers were classified using

categories derived and adapted from previous, similar reviews (Havard, Shakeshaft & Sanson-

Fisher 2008; Webb et al. 2009; Wood et al. 2006): (i) measurement, defined as papers

concerned primarily with developing measurement instruments and/or the psychometric

properties of measurement instruments (n = 26); (ii) descriptive, defined as data-based

descriptive, analytical research on alcohol-related harm (n = 333); (iii) interventions, defined as

evaluation or intervention trials aimed at reducing alcohol-related harm (n = 148); (iv)

dissemination/adoption, defined as studies evaluating methods of ensuring effective

interventions to reduce alcohol-related harm are adopted into routine practice (n = 11); and

(v) reviews, defined as literature reviews (n = 52).

Step 3: exclusion criteria for interventions. Of the 148 intervention papers, 139 were excluded

because: (i) they did not meet the alcohol-related criteria, they did not specifically target

young people or they were delivered in an educational setting (i.e. school, college, or

university) (n = 137); or (ii) they were not published in English (n = 2). The nine remaining

intervention studies were included in the review.

Twenty percent of the articles focused on alcohol (not excluded in Step 1, n = 625) were

classified a second time by a blinded co-author (A.H.) to cross-check the classifications

conducted originally by the first author (B.C.). The articles excluded in Step 1 were not cross-

checked because they were not relevant for the review. Agreement between co-authors was

86%. Discrepancies were discussed and resolved. Due to high agreement between co-authors

and the failure of the hand-searched reference lists to identify additional intervention studies

that met the inclusion criteria, cross-checking more than 20% of article classifications was

deemed unnecessary.

148

Information extraction and summary

Review criteria for data extraction were adapted from the Cochrane Collaboration Handbook

for Systematic Reviews of Health Promotion and Public Health Interventions (Jackson 2007).

The criteria, shown in Table 1, summarize the intervention/s, the sample (including eligibility,

size, age range and percent male), the outcomes measured and the cost calculations

performed.

Methodological critique of intervention studies

Methodological quality was assessed using the Dictionary for the Effective Public Health

Practice Project Quality Assessment Tool for Quantitative Studies (see (Jackson 2007)). Sections

A-F (A, selection bias; B, allocation bias; C, confounders; D, blinding; E, data collection

methods; and F, withdrawal and drop-outs) were coded weak, moderate or strong as advised

by the component rating scale of the Dictionary. For example, a strong rating for section B

(allocation bias) indicates a randomized control trial; a moderate rating for section B indicates

a two-group quasi-experimental design; and a weak rating indicates a case control,

before/after study or no control group (Jackson 2007). Sections G (analysis) and H

(intervention integrity) included descriptive information guided by the Dictionary.

Results

Interventions

Nine intervention studies were included: eight counselling-based interventions and one

medically-based intervention. Of the counselling interventions, seven had individual session/s

for the young person (D'Amico et al. 2008; Esposito-Smythers et al. 2006; Peterson et al. 2006;

149

Slesnick et al. 2007; Stein et al. 2006; Kemp et al. 2007), three included family-based therapy

(Esposito-Smythers et al. 2006; Liddle et al. 2009; Slesnick et al. 2006) and one included group-

based therapy (Liddle et al. 2009). Counselling interventions were based on motivational

interviewing (MI) (D'Amico et al. 2008; Peterson et al. 2006; Stein et al. 2006; Kemp et al.

2007), cognitive-behavioural therapy (CBT) (Esposito-Smythers et al. 2006; Liddle et al. 2009;

Kemp et al. 2007), family therapy (Esposito-Smythers et al. 2006; Liddle et al. 2009; Slesnick et

al. 2006) and/or an operant perspective community-reinforcement approach (Slesnick et al.

2007; Slesnick et al. 2006). The number of reported counselling sessions ranged from one

(D'Amico et al. 2008; Peterson et al. 2006; Stein et al. 2006) to 32 (Liddle et al. 2009). The

medically-based intervention investigated the efficacy of medicating alcohol-dependent

adolescents with a serotonin-3 antagonsit (ondansetron) (Dawes et al. 2005).

150

Table 1. Interventions for young people experiencing alcohol -related harm

First author

and year of

publication

(reference)

Intervention/s

(number of

sessions)

Sample Eligibility Age

range,

years (%

male)

Data collection

methods

Outcomes Cost

calculation?

D’Amico,

2008

(D'Amico et

al. 2008)

BMI: Project CHAT

(1)

Underserved

populationa

(n = 64)

Scoring 1 or more on

the CRAFFT

(screening

instrument for drug

and alcohol use)

12-18

(48%)

Self-report only

(self-complete)

Alcohol and marijuanna:

Intentions

Percieved prevalence

Number of friends who consume

How often teens consume

Consequences

Past month prevalence

How many drinks consumed in past

month

Number of days consumed 3+

drinks in the past month

Dawes, 2006

(Dawes et al.

2005)

Medication Treatment-

seeking patients

(n = 12)

DSM-IV diagnosis of

alcohol dependence

14-20

(58%)

Self-report only

(self-complete)

Number of days drinking

Number of drinks each day

Percentage of days abstinent

Side effects of medication

Esposito-

Smythers,

2006

(Esposito-

Smythers et

al. 2006)

CBT & family

therapy sessions

(12-15)

Co-occuring

alcohol use

disorder and

suicidality

(n = 6)

Alcohol use disorder Mean=15

(17%)

Self-report only

(self-complete)

Number of days drinking

Number of heavy drinking days

Number of days of cannabis use

Suicidal ideation

Suicide attempts

151

First author

and year of

publication

(reference)

Intervention/s

(number of

sessions)


range,

years (%

male)

Data collection

methods

Outcomes Cost

calculation?

Kemp, 2007

(Kemp et al.

2007)

‘Stop Using Stuff’ -

MI and CBT (4-6)

Primary

diagnosis of a

DSM-IV

psychotic illness

and substance

abuse

Substance abuse

diagnosis by the

DAST-10 ≥ 3; AUDIT ≥

6

17-25

(81%)

Self-report only

(self-complete +

clinical interview)

Alcohol use

Drug use

Positive and negative affect

Self-efficacy

Quality of life

Liddle, 2009

(Liddle et al.

2009)

Multi-dimensional

family therapy (25-

32)

CBT-based peer

group intervention

(25-32)

Youth and their

parent/s

(n = 83)

Youth refered for

treatment for a

substance abuse

problem

11-15

(74%)

Self-report only

(self-complete +

parent and

adolescent

interviews)

Past-month alcohol, marijuana and

other drug use

Delinquency

Internalized distress

Family interactions

Peer delinquency

School achivement and behaviour

Peterson,

2006

(Peterson et

al. 2006)

BMI (1) Homeless

(n = 285)

At least 1 episode of

drinking 4+ drinks for

females or 5+ drinks

for males or used

illicit ‘street’ drugs at

least four times in

the past 30 days

13-19

(56%)

Self-report (self-

complete +

interview) and

urine testing for

drugs (not

including alcohol)

Past-month alcohol use

Illicit drug use

152

First author

and year of

publication

(reference)

Intervention/s

(number of

sessions)


range,

years (%

male)

Data collection

methods

Outcomes Cost

calculation?

Slesnick,

2006

(Slesnick et

al. 2006)

Ecologically based

family therapy (10)

Runaways

(n = 202)

DSM-IV criteria for

drug or alcohol use

disorder

12-17

(44%)

Self-report only

(self-complete)

Substance use

Conflict resolution

Youth’s perceived attitudes of parental

bonding and over protection

Social-enviromental characteristics of

families

Delinquency

Slesnick,

2007

(Slesnick et

al. 2007)

Community

Reinforcement

Approach (12)

Homeless

(n = 180)

DSM-IV alcohol or

other psychoactive

substance use

disorder

14-22

(66%)

Self-report only

(self-complete +

interview)

Substance use in recent weeks

Delinquency

Coping

Depression

HIV knowledge and attitudes

Stein, 2006

(Stein et al.

2006)

MI (1) Incarcerated

(n = 125)

Marijuana and

alcohol use

(abuse/dependence)

in the month prior to

incarceration as well

as driving under the

influence or

passenger with driver

under the influence

14-19

(90%)

Self-report (self-

complete +

structured clinical

interveiw) and

driving record

review

Driving under the influence

Passenger with driver under the

influence

Depression

AUDIT: Alcohol Use Disorders Identification Test; BMI: brief motivational interviewing; CBT: cognitive behavioural therapy; CRAFFT: Car Relax Alone Forget Friends Trouble;

DAST: Drug Abuse Screening Test; MI: motivational interviewing. aDescribed as: the uninsured; the working poor; homeless; runaway; and high-risk youth who reported

alcohol consumption and drug use and some consquences due to use.

153

Samples and eligibility

The sampled youth population varied across studies, including: the underserved, described as

the uninsured, working poor, homeless, runaway and high-risk youth (D'Amico et al. 2008);

treatment seeking individuals (Dawes et al. 2005); those with comorbid suicidality (Esposito-

Smythers et al. 2006); those with a primary diagnosis of a psychotic illness and substance

abuse (Kemp et al. 2007); young people and their parents (Liddle et al. 2009); runaways

(Slesnick et al. 2006); the homeless (Peterson et al. 2006; Slesnick et al. 2007); and

incarcerated youth (Stein et al. 2006). The young people ranged in age from 11 to 25 years and

the percent of male participants from 17% to 90%. Although participants were screened

appropriately for an alcohol/substance use disorder (Esposito-Smythers et al. 2006; Liddle et

al. 2009; Slesnick et al. 2007; Dawes et al. 2005; Slesnick et al. 2006; Kemp et al. 2007) or

problematic alcohol use (D'Amico et al. 2008; Peterson et al. 2006; Stein et al. 2006), two

studies gave no clear definition of the cut-off score for eligibility for inclusion (Esposito-

Smythers et al. 2006; Liddle et al. 2009) and all except one (Stein et al. 2006) used self-report

eligibility criteria.

Data collection methods and outcomes

All studies used self-report measures. Table 1 shows seven studies used self-report measures

only; three of these used both self-complete and interview techniques (Liddle et al. 2009;

Slesnick et al. 2007; Kemp et al. 2007) and four used self-complete only (D'Amico et al. 2008;

Dawes et al. 2005; Esposito-Smythers et al. 2006; Slesnick et al. 2006). Of the two studies that

used non-self-report measures, one used urine tests for drugs (not including alcohol) (Peterson

et al. 2006) and one used driving record checks for reports of driving under the influence of

alcohol (only amongst participants who where old enough to obtain a driving permit) (Stein et

al. 2006).

154

Alcohol use outcomes were measured across all studies but varied: recent alcohol use

(D'Amico et al. 2008; Liddle et al. 2009; Peterson et al. 2006; Slesnick et al. 2007; Kemp et al.

2007); frequency/quantity of alcohol use (D'Amico et al. 2008; Esposito-Smythers et al. 2006;

Dawes et al. 2005; Slesnick et al. 2006; Kemp et al. 2007); heavy alcohol use or alcohol use

disorders (D'Amico et al. 2008; Esposito-Smythers et al. 2006); and driving under the influence

of alcohol (Stein et al. 2006). Other outcome measures included: other drug use/abuse

(D'Amico et al. 2008; Peterson et al. 2006; Slesnick et al. 2007; Slesnick et al. 2006; Kemp et al.

2007; Esposito-Smythers et al. 2006); alcohol and/or drug perceptions and intentions to use

(D'Amico et al. 2008); suicide ideation and attempts (Esposito-Smythers et al. 2006); family

interactions (Liddle et al. 2009); conflict resolution (Slesnick et al. 2006); social-environmental

characteristics of families (Slesnick et al. 2006); youth’s perceived attitudes of parental

bonding and overprotection (Slesnick et al. 2006); delinquency (Liddle et al. 2009; Slesnick et

al. 2007; Slesnick et al. 2006); school achievement and behaviour (Liddle et al. 2009);

experienced affect or affective disorders (Stein et al. 2006; Liddle et al. 2009; Slesnick et al.

2007; Kemp et al. 2007); coping (Slesnick et al. 2007); human immunodeficiecy virus (HIV)

knowledge and attitudes (Slesnick et al. 2007); self-efficacy (Kemp et al. 2007); quality of life

(Kemp et al. 2007); and medication side effects (Dawes et al. 2005).

Eight studies were conducted in the United States (D'Amico et al. 2008; Esposito-Smythers et

al. 2006; Liddle et al. 2009; Peterson et al. 2006; Slesnick et al. 2007; Stein et al. 2006; Dawes

et al. 2005; Slesnick et al. 2006) and one study was from Australia (Kemp et al. 2007).


Table 2 summarises the methodological adequacy of the nine studies. Two studies obtained a

100% consent rate, obviating the possibility of selection bias (Liddle et al. 2009; Stein et al.

2006). A randomized control trial was employed by seven of the nine studies (D'Amico et al.

155

2008; Liddle et al. 2009; Peterson et al. 2006; Slesnick et al. 2007; Stein et al. 2006; Kemp et al.

2007; Slesnick et al. 2006), minimizing the risk of allocation bias. Baseline differences in

comparison groups were not controlled in the analyses, so it is difficult to know the extent to

which reported post-test differences are attributable to the intervention. More than half the

studies used outcome assessors that were not blinded (Liddle et al. 2009; Peterson et al. 2006;

Slesnick et al. 2007; Stein et al. 2006; Kemp et al. 2007). Six studies used measures with

demonstrated validity and reliability (Liddle et al. 2009; Peterson et al. 2006; Slesnick et al.

2007; Stein et al. 2006; Slesnick et al. 2006; Kemp et al. 2007), one used measures of known

validity but unknown reliability (D'Amico et al. 2008) and two studies used measures that were

not tested psychometrically (Esposito-Smythers et al. 2006; Dawes et al. 2005). Five studies

had follow-up rates between 80% and 100% (Esposito-Smythers et al. 2006; Slesnick et al.

2007; Stein et al. 2006; Slesnick et al. 2006; Kemp et al. 2007), one study had a follow-up rate

between 60% and 79% (Peterson et al. 2006), and three studies had follow-up rates less than

60%: 50% (Dawes et al. 2005; Liddle et al. 2009) and 34% (D'Amico et al. 2008).

156

Table 2. Methodological adequacy of reviewed studies

First author

and year of

publication

(reference)

Selection

bias (A)

Allocation

bias (B)

Confounders

(C)

Blinding

(D)

Data

collection

methods

(E)

Withdrawal

& drop-outs

(F)

Analysis (G) Intervention integrity (H)

D’Amico,

2008a

(D'Amico et

al. 2008)

Weak Strong Weak N/A Moderate Weak No citation for formula used in

the analysis

Cannot tell if intent-to-treat

analysis was conducted

9% consent rate, 34% follow-up rate

59% of participants revieved the

intervention

Therapists were trained in MI by a clinical

psychologist who is certifed by the

Motivational Interviewing Network or

Trainers

Dawes, 2005

(Dawes et al.

2005)

Weak Weak Weak N/A Weak Weak No citation for formula used in

the analysis

Intent-to-treat analysis

included

Consent rate not reported, 50% follow-

up rate

All participants received the intervention

CBT was given in addition to prescribed

medication and this may have influenced

the results

Esposito-

Smythers,

2006

(Esposito-

Smythers et

al. 2006)

Weak Weak Weak N/A Weak Strong No citation for formula used in

the analysis




up rate

All participants received the intervention

CBT manual was developed

157

First author

and year of

publication

(reference)

Selection

bias (A)

Allocation

bias (B)

Confounders

(C)

Blinding

(D)

Data

collection

methods

(E)

Withdrawal

& drop-outs

(F)


Kemp, 2007a

(Kemp et al.

2007)

Weak Strong Weak Weak Strong Strong No citation for formula used in

the analysis




up rate

63% of participants received the

intervention

Battery of measures used but no

comment about how they were delivered

Liddle, 2009 a

(Liddle et al.

2009)

Strong Strong Weak Weak Strong Weak Citation for analysis included

Intent-to-treat analysis

included



intervetion

Self-report and observation methods

indicated that groups were conducted in

line with treatment content and

guidelines

Peterson,

2006 a

(Peterson et

al. 2006)

Weak Strong Weak Weak Strong Moderate No citation for formula used in

the analysis




up rate

Number of participants receiving the

intervention not stated

Therapists were trained in motivational

interviewing and supervised including

reviews of taped sessions

158

First author

and year of

publication

(reference)

Selection

bias (A)

Allocation

bias (B)

Confounders

(C)

Blinding

(D)

Data

collection

methods

(E)

Withdrawal

& drop-outs

(F)


Slesnick,

2006 a

(Slesnick et

al. 2006)

Weak Strong Weak N/A Strong Strong No citation for formula used in

the analysis




up rate

50% of participants recieved the

intervetnion

Therapists were trained, sessions were

audiotaped for treatment adherence

checks

Slesnick,

2007 a

(Slesnick et

al. 2007)

Weak Strong Weak Weak Strong Strong No citation for formula used in

the analysis

All analyses were intent-to-

treat


up rate


intervention

Therapists were trained, details of

session focus were reported

Stein, 2006 a

(Stein et al.

2006)

Strong Strong Weak Weak Strong Strong No citation for formula used in

the analysis

No intent-to-treat analysis

reported


Number of participants receiving the

intervention not stated

Therapists were trained in motivational

interveiwing and supervised including

review of case files

Control group received relaxation

training that may have impacted on

measured outcomes

Measured by the Dictionary for the effective public health practice project quality assessment tool for quantitative studies (see (Jackson 2007)). CBT: cognitive behavioural

therapy; MI: motivational interviewing; N/A: not applicable. aRandomized control trial.

159

One study provided support for the appropriateness of its analysis by referencing a book about

their general statistical approach (Liddle et al. 2009). Participation consent rates varied from

9% (D'Amico et al. 2008) to 100% (Liddle et al. 2009; Stein et al. 2006) and intent-to-treat

analyses were reported by three studies (Slesnick et al. 2007; Dawes et al. 2005; Liddle et al.

2009). In two studies, all participants received the intervention (Dawes et al. 2005; Esposito-

Smythers et al. 2006). Of the seven studies with a control group, five reported that more than

half the participants were in the intervention group (Slesnick et al. 2007; D'Amico et al. 2008;

Liddle et al. 2009; Slesnick et al. 2006; Kemp et al. 2007). Methods to optimize consistency in

the delivery of interventions were not described in two studies (Dawes et al. 2005; Kemp et al.

2007). When they were described, methods included training therapists (D'Amico et al. 2008;

Peterson et al. 2006; Slesnick et al. 2007; Stein et al. 2006; Slesnick et al. 2006), developing

manuals (Esposito-Smythers et al. 2006), audio-taping for adherence to treatment protocols

(Peterson et al. 2006; Slesnick et al. 2006) and self-report or observation (Liddle et al. 2009).

Contamination was likely for Dawes et al. because CBT was provided in addition to the medical

intervention that was the focus of the study (Dawes et al. 2005).

Effects

Due to the generally weak methodological quality of the included studies, especially their

susceptability to intervention confounding and lack of blinding, the effect sizes are likely to be

biased and, therefore, were not summarized. A meta-analysis using the most commonly

reported outcomes was explored but judged inappropriate, given the variability between

studies in the outcomes reported. No interventions included a cost or economic analysis.

160

Discussion

This systematic review of available peer-reviewed studies evaluating interventions delivered

outside educational settings, designed for young people with existing alcohol use problems or

who participate in behaviour that places them at high-risk of alcohol-related harm, identified

eight counselling-based interventions (Kemp et al. 2007; D'Amico et al. 2008; Esposito-

Smythers et al. 2006; Liddle et al. 2009; Peterson et al. 2006; Slesnick et al. 2007; Stein et al.

2006; Slesnick et al. 2006) and one medically-based intervention (Dawes et al. 2005). Six

counselling studies had an individual focus (D'Amico et al. 2008; Esposito-Smythers et al. 2006;

Peterson et al. 2006; Slesnick et al. 2007; Stein et al. 2006; Kemp et al. 2007) and three

included family and peers (Liddle et al. 2009; Esposito-Smythers et al. 2006; Slesnick et al.

2006). Counselling types varied across the eight studies: family-based, MI, CBT and community

reinforcement. Length of the interventions were also diverse: three used brief interventions

(one session) (D'Amico et al. 2008; Peterson et al. 2006; Stein et al. 2006), four had between

two and fifteen sessions (Esposito-Smythers et al. 2006; Kemp et al. 2007; Slesnick et al. 2006;

Slesnick et al. 2007), and one had 25-32 sessions (Liddle et al. 2009).


None of the included intervention studies had consistently strong methodology. Weak ratings

were commonly recorded for selection bias and confounding, while allocation bias was mainly

rated strongly across studies. Blinding was rated weakly when applicable. Data collection

methods were generally appropriate, with seven studies using measures with some published

evidence of their reliability and validity. Withdrawal and dropout ratings also varied across

studies, ranging from 22% to 86%. Statistical analyses used were rarely supported by a citation

of source and intent-to-treat analyses were conducted for only a third of studies. Consent

rates varied from 9% to 100% and follow-up rates ranged from 34% to 86%, when reported.

Therapists were trained and supervised.

161

Limitations of the available literature

In addition to methodological adequacy, the substantial variation in the eligibility criteria

across studies limits the validity of comparisons between them. Although a primary eligibility

criterion was either an alcohol use disorder or problem, no studies screened participants in the

same way. Screening using standardized measures of alcohol dependence or misuse, such as

the AUDIT (Saunders et al. 1993) or DSM-IV criteria (American Psychiatric Association 1994),

would improve comparability between studies.

Another limitation of the available literature relates to measurement. First, one study grouped

alcohol and drug use outcomes together, increasing the difficulty of determining the impact of

their intervention specifically on alcohol-related harm (Slesnick et al. 2007). Secondly, since

self-report data are prone to bias, even when bias is minimized by using psychometrically

validated tools (Hogan 2003), complementary objective measures would increase the rigour of

intervention outcome measures. Despite this, seven studies in this review only used self-report

measures (D'Amico et al. 2008; Esposito-Smythers et al. 2006; Liddle et al. 2009; Slesnick et al.

2007; Dawes et al. 2005; Slesnick et al. 2006; Kemp et al. 2007). Of the two that used objective

measures, one used urine tests for drug use but did not test for alcohol use (Peterson et al.

2006), and the other reviewed driving records (Stein et al. 2006). A number of more objective

measures suitable for evaluating alcohol harm interventions are emerging, including measures

of alcohol-related crime, traffic accidents and emergency department presentations (Breen et

al. 2011a; Czech et al. 2010; Shakeshaft, Doran & Byrnes 2009).

Eight of the nine identified studies were conducted in the United States which limits

generalizability to other countries. Although outcomes of interventions evaluated in the

United States may be applicable to other high-income countries in so far as they share similar

162

socio-economic factors and infrastructure for young people, between-country differences in

drinking prevalence and patterns (World Health Organization 2004), as well as different legal

drinking ages, might lead to different intervention effects in different countries. Rigorous

evaluation trials, conducted in countries other than the United States, would be valuable

additions to the evidence base.

Finally, there was no consideration of costs in any of the included studies. Economic analysis

provides an important contribution by costing and valuing reductions in alcohol-related harm,

as well as providing a benchmark to evaluate potential savings associated with interventions.

Although the economic cost of alcohol misuse among young people has not been measured

(Doyle, Delaney & Tobin 1994), the associated rates of alcohol-related health service utilization

and crime are high. Accumulated over a life-time, these harms are likely to result in a

substantial cost to society with minimal off-set of those costs through tax contributions

(McGorry et al. 2007; Pacileo & Fattore 2009; Cohen 1998).

Intervention effects

Despite their methodological limitations, the studies identified by this systematic review

represent best evidence for the effectiveness of interventions for young people with existing

alcohol use problems or who participate in behaviour that places them at high risk of harm.

The most promising approaches to reduce such harms are CBT (Esposito-Smythers et al. 2006;

Kemp et al. 2007), family therapy (Liddle et al. 2009; Slesnick et al. 2006) and community

reinforcement (Slesnick et al. 2007). Evaluations using more rigorous methodologies are

required before clear conclusions can be reached about the most effective interventions to

reduce alcohol-related harms among youth who have existing alcohol use problems, or who

participate in behaviour that places them at high risk of harm.

163

Limitations of the review

The possibility that this systematic review did not locate all relevant studies is unlikely: 10

electronic databases were searched by researchers, seven collections checked by a senior

librarian and reference lists of review articles examined. Relevant identified studies may have

been excluded or misclassified, but this is also unlikely given high agreement between blinded

coders (86%).

Because this review is limited to intervention studies published in 2005-09, effective

interventions published prior to 2005 are excluded. A comprehensive review of relevant

interventions published prior to 2000, however, identified only family therapy and community

reinforcement as interventions with evidence for their effectiveness (Williams & Chang 2000).

For the period 2000-04, the 52 reviews identified in this review (Fig. 1) were examined and 14

reviews of intervention studies were identified. Hand-searching their reference lists located

four individual treatment outcome studies (Kaminer, Burleson & Goldberger 2002; Liddle et al.

2001; Wells-Parker & Williams 2002; Kypri et al. 2004), only two of which showed significant

effects: one for CBT (Kaminer, Burleson & Goldberger 2002) and the other for family therapy

(Liddle et al. 2001). In total, therefore, prior to 2005 three intervention types have been

identified with evidence for their effectiveness, all of which were included in this review. This

suggests effective interventions are unlikely to have been omitted. As might be expected, it

also indicates that the number of intervention studies is increasing over time: four between

2000 and 2004 and nine between 2005 and 2009. It is likely, however, that these published

evaluations overestimate the true intervention effectiveness, as evaluations with statistically

significant findings are more likely to be published (Dickersin et al. 1987; Easterbrook et al.

1991).

164

Although this review focused on interventions to reduce alcohol-related harm, multi-modal

interventions that address alcohol and other common comorbid issues are likely to increase

benefits for young people and their communities (Bauman & Phongsavan 1999), because

alcohol misuse is associated commonly with other harms, particularly illicit drug use (Regier et

al. 1990; Teesson et al. 2010). All but one study in this review included illicit drug use in the

sample characteristics and/or as an outcome (D'Amico et al. 2008; Esposito-Smythers et al.

2006; Kemp et al. 2007; Liddle et al. 2009; Peterson et al. 2006; Slesnick et al. 2006; Slesnick et

al. 2007; Stein et al. 2006).

Future opportunities for methodologically adequate intervention studies

The published intervention studies delivered outside of educational settings, designed for

young people with existing alcohol use problems or who participate in behaviour that places

them at high risk of alcohol-related harm, have substantial methodological limitations that

make it difficult to interpret their results. Future intervention trials need to be more rigorous,

particularly in terms of their study designs, sample recruitment and follow-up and statistical

analyses. It is also clear that individualistic approaches have been the focus of interventions

evaluated to date. Given the complex, multi-dimensional nature of problems experienced by

highly disadvantaged young people, it is likely that programs that engage with the broader

social context and community resources, as well as individual factors, will be more cost-

effective (Mortimer & Segal 2005). As a minimum, replication of these interventions in studies

outside the United States would increase the generalizability of their results.

Conclusions

Given the extent of costs and harms associated with risky alcohol use by young people, there is

a clear need for a greater number of methodologically rigorous evaluations of interventions

165

targeting high-risk young people and those experiencing alcohol-related harm, particularly

with a focus broader than the individual.

Acknowledgements

We would like to thank Associate Professor Christopher Doran for providing advice on the

paper’s content. Funding was provided by the Alcohol Education and Rehabilitation

Foundation as part of the Alcohol Action in Rural Communities project.

166


Addiction owns the copyright of this published paper. The points of clarification have been

added to provide additional information about the research for this thesis without modifying

the content of the published paper.

Resolution of classification discrepancies

Coders met to discuss classification discrepancies. Consensus was reached through re-

examining the identified studies and agreeing on the appropriate classification.

167

Implications and future directions

168

The feasibility and benefits of creating partnerships between researchers, health care

providers and Indigenous Australians

The work contained in this thesis demonstrates a process of researchers working in

partnership with health care providers and Indigenous Australians to improve the

development of Indigenous-specific interventions for implementation into routine health care.

The systematic review of the peer-reviewed literature completed in Paper 1 (Calabria et al.

2012) identified family-based interventions as having some evidence for their effectiveness

and having the most potential to be tailored to Indigenous people to reduce their experience

of alcohol-related harm, specifically Community Reinforcement and Family Training (CRAFT).

CRAFT and the Community Reinforcement Approach (CRA) (an evidence-based intervention for

problem drinkers on which the development of CRAFT was based) were then tailored to the

requirements of the health care providers who would be likely to deliver them (Paper 3

(Calabria et al. submitted-a)) and their level of acceptability to potential Indigenous clients of

health care services was examined (Paper 4 (Calabria et al. 2013)).

This consultation process determined that CRA and CRAFT could be modified to optimise their

acceptability to Indigenous people in the local community and local health care providers. The

major modifications to CRA and CRAFT were to convert the technical language in the

intervention resources and CRA and CRAFT manuals to a more local dialect, and to introduce

the possibility of group sessions to complement individual counselling sessions. Health care

providers at a rural drug and alcohol treatment agency have now been trained and certified in

the delivery of both interventions, and a local supervision and training program has been

established to provide ongoing support for certified health care providers delivering CRA and

CRAFT. Furthermore, sufficient capacity has now been built to enable the training and

certification of new health care providers in other local communities. Ongoing referral

pathways into CRA and CRAFT have been newly established, or existing pathways improved,

169

through a range of different agencies including, for example, probation and parole, and local

Aboriginal Medical Services. Finally, a package of outcome measures has been developed that

is acceptable for use by health care providers, and could be used by researchers or health care

providers to assess the outcomes of clients participating in the tailored CRA and CRAFT

interventions.

The consultation process also identified a perceived need for interventions targeting young

Indigenous people at high risk of alcohol-related harm. Research evidence was found to

support this perceived need in two separate ways: an epidemiological analysis which

confirmed the disproportionately high negative impact on young Indigenous people (Paper 5

(Calabria et al. 2010); and a systematic review of the literature that identified the potential

effectiveness of CRA with adolescents (Paper 6 (Calabria, Shakeshaft & Havard 2011)). An

adolescent version of CRA (A-CRA) has been recently developed, that includes parents in the

therapeutic approach (Garner, Barnes & Godley 2009; Garner et al. 2009; Godley et al. 2007;

Godley, Hedges & Hunter 2011; Godley et al. 2001; Godley et al. 2009; Smith et al. 2011).

Although A-CRA is also a United States based intervention, it derives from the same principles

as CRA and CRAFT and the evidence presented in this thesis strongly suggests that it could also

be tailored to optimise its acceptability to both health care providers (Paper 3 (Calabria et al.

submitted-a)) and Indigenous adolescents (Paper 4 (Calabria et al. 2013)).

This demonstrated process of tailoring interventions, through evidence informing practice and

practice and perceived needs informing research, is highly consistent with the definition of

translational research (Marincola 2003; Havard Catalyst 2013). This process is not linear; what

matters is the maintenance of the complementary relationship between research and practice.

This optimises the likelihood that current best evidence will be used to inform the

development of Indigenous-specific interventions aimed to meet the identified and perceived

170

needs of Indigenous Australians in an acceptable and feasible manner. Evidence-based

medicine is defined as integrating clinical experience with clinical research evidence (Sackett et

al. 1996), which is clearly consistent with the principle of translation research. The next step

after an intervention has been identified and tailored for health care providers and Indigenous

Australians is to evaluate both its effectiveness and costs. Intervention evaluation that

demonstrates cost-effectiveness has the potential to contribute to improvements in

Indigenous health (Paul et al. 2010). The evaluation itself will require effective and consultative

partnerships (Gray et al. 2000), primarily to provide ongoing feedback to health care providers

and Indigenous communities on outcomes and to facilitate ongoing modification of

intervention programs to improve their effectiveness, or the economic efficiency with which

they can be delivered. Although cost-effectiveness analyses are important in determining the

relative efficiency with which different interventions are provided, they are limited by the

assumptions that underpin the models used and the quality of the data available to populate

them (Drummond et al. 2005). Furthermore, interventions that are not cost-effective, but do

have evidence for their effectiveness, can still provide health benefits.

Developing guiding principles for researchers working in partnership with Indigenous

Australians and health care providers to improve intervention research

Through the process of working in partnership with health care providers and Indigenous

Australians to improve intervention research, three guiding principles began to emerge that

could be useful for other groups aiming to tailor, implement and evaluate Indigenous-specific

interventions: 1) consultation between researchers, health care providers and Indigenous

Australians is required from intervention identification and modification, through to

implementation and evaluation; 2) finding a balance between methodologically rigorous

research and intervention implementation in a real world setting; 3) building capacity to

171

ensure the delivery of effective interventions is sustained beyond the timeframe of any

research project.

Guiding principles have been previously published for implementing community interventions

among Indigenous people in Canada (Potvin et al. 2003). The authors of those guiding

principles state that similar principles date back to the 1950s, but highlight the importance of

demonstrating the principles in their current research context. Therefore, although the

Canadian guiding principles are similar to those proposed by this thesis, there is merit in

attempting to demonstrate the applicability of these types of principles to the Australian

Indigenous context.

Principle 1: consultation between researchers, health care providers and Indigenous

Australians is required from intervention identification and modification, through to

implementation and evaluation

Consultation between researchers and Indigenous Australians about Indigenous-specific

research acknowledges and respects Indigenous people’s right to self-determination, their

differences in cultural beliefs and systems, and the diversity of Indigenous people (United

Nations 2008; Australian Institute of Aboriginal and Torres Strait Islander Studies 2010;

National Health and Medical Research Council 2003). For these reasons consultation is an

ethical requirement for Indigenous research (National Health and Medical Research Council

2003). Consultation with health care providers that are likely to deliver Indigenous-specific

interventions increases the likelihood of the interventions being feasible to implement and

being sustained beyond the life of a defined research project. Indigenous Australians and

health care providers who work with Indigenous people should be actively involved in

Indigenous-specific research from conception to evaluation. This thesis has demonstrated that

172

it is feasible to establish a process whereby evidence informs practice, and practice and

perceived needs informs research. Although this is a lengthy process, it has the potential to

improve the quality of Indigenous-specific research, which to date has been shown to be less

than adequate (Sanson-Fisher et al. 2006; Clifford et al. 2010; Shakeshaft, Clifford &

Shakeshaft 2010). Researcher consultation with health care providers and Indigenous

Australians should continue after the specific intervention has been developed, to improve

both the implementation and evaluation phase.

Ensuring the acceptability of rigorous research design and measures to health care providers

who delivered the interventions, and to Indigenous Australians, was a key requirement

identified in this thesis. This did not mean that the methodological quality of the research had

to be diluted to ensure its acceptability to health care providers and Indigenous Australians.

Rather, it meant that the type of, and need for, various research methods needed to be clearly

communicated to health care providers involved in the evaluation, specifically highlighting the

stages of intervention development through to evaluation: 1) tailor the intervention; 2)

implement tailored intervention; 3) measure its effectiveness (ensuring that the agreed

intervention is delivered consistently); and 4) analyse the outcome data. For this doctoral

project the needs and suggestions of health care providers and Indigenous Australians were

incorporated into the research, even when they led to modification to the original research

plan, providing the modifications did not excessively dilute the reliability and validity of the

outcomes. Finding this balance was difficult and required ongoing communication and

negotiations between all those engaged in the partnership.

Principle 2: finding a balance between methodologically rigorous research and

intervention implementation in a real world setting

173

A balance between rigorous research design and methods, and real world service delivery

must be reached. Research methods need to be sufficiently flexible to fit into the routine care

of clients and health care providers need to be open to incorporate some evaluation

components into their usual work. Establishing a trusting and co-operative relationship

between researchers and health care providers aimed at benefiting the local Indigenous

community is essential to finding the research-real-world-balance (Clapham 2011; Potvin et al.

2003).

Rigorous evaluation gives the best chance of determining the true effects of an intervention.

The absence of a controlled design can limit the findings of an evaluation because any

observed differences between pre- and post-intervention outcomes cannot confidently be

attributed to the intervention being evaluated, independently of other co-occurring factors

that may have influenced the outcome over time (Jackson 2007; Chambless & Hollon 1998).

Despite being the ‘gold standard’ for efficacy research (Sibbald & Roland 1998), randomised

controlled trials (RCTs) are not always appropriate when interventions are delivered in

naturalistic settings (Seligman 1995).

Randomised controlled trials randomly allocate recruited participants or groups into the

intervention or control condition (Sibbald & Roland 1998). When individuals are the unit of

analysis, eligible individuals are randomised to receive either the intervention or the control

condition, which could be treatment as usual or no treatment. Individual outcome measures

are used to evaluate the effectiveness of the intervention and can include self-reported survey

data or routinely collected individual data (e.g. Medicare data). Group randomisation is

appropriate for evaluating interventions that are implemented across whole communities, or

within schools, or health care services, such as Indigenous primary care practices. The two

most rigorous evaluation designs appropriate to group randomisation have been identified as:

174

1) a cluster RCT where the groups are randomly assigned to the intervention or control

condition (Campbell et al. 2000); and 2) a stepped wedge or multiple baseline design (MBD)

where groups are randomised to start intervention delivery at staggered intervals (e.g. 6

months, 12 months and 18 months) (Hawkins et al. 2007). Both these design options allow

active engagement of a range of health and other community services. Self-reported and

routinely collected community-level, or service-level, data (e.g. community surveys, police

counts of alcohol-related assaults, or audits of client medical records) are outcome measures

that are highly appropriate to cluster RCT or MBD evaluation designs.

Randomised controlled trials that randomise individuals are not feasible to implement in

Indigenous communities and Indigenous-specific health care services where there are many

familial connections and strong community cohesion (Stewart et al. 2010). Randomising whole

communities or services would minimise the potential for contamination between intervention

and control groups, but cluster RCTs are an expensive and time consuming evaluation design

(Biglan, Ary & Wagenaar 2000). For example, a recent community-level cluster RCT conducted

with rural communities in New South Wales (NSW) to reduce alcohol harm cost approximately

$A2.3 million and took six years to complete (Shakeshaft et al. 2012). These practical reasons

could help explain the lack of rigorous evaluation research focused on Indigenous health (Paul

et al. 2010; Sanson-Fisher et al. 2006; Clapham 2011). The MBD, as an alternative to a cluster

RCT, is less expensive to implement because each community effectively acts as its own

control, meaning this evaluation could be done with as few as two communities or health care

services. Although the level of evidence it generates is less rigorous than in a cluster RCT, it is

sufficiently rigorous to be used as the basis for policy and health service delivery decisions

(Hawkins et al. 2007). Nevertheless, MBD evaluations are still expensive compared to simpler

designs, such as a pre- and post-evaluation design with one group, because they typically

evaluate complex interventions that involve multiple key stakeholders and are logistically

175

difficult, time consuming and require high level research skills to implement (Hawkins et al.

2007).

The relatively high cost and complexity of both cluster RCTs and MBDs potentially highlights

the particular value of a more staged approach to real world intervention research. These

stages could involve a process of defining and tailoring an intervention and outcome measures,

as has been the focus of this thesis. The next stage could be a relatively simple evaluation of

the agreed intervention using a pre- and post-evaluation design. Although a pre- and post-

evaluation design does not provide the strength of evidence of an RCT or MBD, it does provide

sufficient evidence to justify the expense and time commitment required for a large-scale trial,

the conduct of which could be the final stage in this stepped approach to real world

Indigenous intervention research. It is probable that a key criticism of this approach would be

the time that is required to go through these stages in order to produce rigorous evidence, but

existing reviews have clearly shown that very little high quality Indigenous evaluation research

has been published over the last 20 years in Australia or internationally (Sanson-Fisher et al.

2006; Clifford et al. 2010; Shakeshaft, Clifford & Shakeshaft 2010), which suggests

implementing this staged approach over a period of approximately 5-6 years would produce

more high quality outcomes than has been achieved to date.

Reliable and valid measures are necessary to accurately assess the outcomes of an

intervention, regardless of the evaluation design (Streiner & Norman 2008). Specifically,

measures designed, or validated, for Indigenous people should be used when conducting

research with this group. Paper 2 (Calabria et al. submitted-b) identified Indigenous-specific

cut-off scores on two shorter versions of the Alcohol Use Disorders Identification Test (AUDIT):

AUDIT-C and AUDIT-3. These measures can be used to classify the drinking risk status of new

clients, to determine the most appropriate intervention for them, or to measure participant

176

outcomes before and after intervention delivery. AUDIT was designed as a cross cultural

screening instrument (Babor et al. 1989; Saunders et al. 1993) but Indigenous-specific cut-off

scores for two shorter versions (AUDIT-C and AUDIT-3) have not previously been published. As

well as identifying Indigenous drinking risk status using AUDIT-C and AUDIT-3, the Indigenous-

specific cut-off scores on these shorter versions of the AUDIT can be used to reduce the time it

takes to complete the AUDIT, an issue that has previously been identified as a barrier to its

routine use (Brady et al. 2002; Clifford & Shakeshaft 2011).

Another measure, that was designed for Indigenous Australians and has been validated among

this population, is the Growth Empowerment Measure (GEM) (Haswell et al. 2010). The GEM

measures Indigenous people’s social and emotional wellbeing. The measure consists of the

Emotion Empowerment Scale (EES14) and twelve scenarios (12S). This Indigenous-specific

measure shows great potential to be used in intervention evaluations.

An issue identified in this research was the problem of researchers imposing an additional data

collection burden on both health care providers and clients, as a consequence of requiring

evaluation-specific outcomes to be assessed pre- and post- intervention. A solution that was

identified in this project was to ensure that, as far as possible, the outcome measures were

brief (e.g. testing shorter forms of AUDIT) and aligned with the routine reporting requirements

of health care providers and the health care services. Anecdotally, this project showed

acceptable compromises about which questions needed to be asked, and the required data

collection time points were able to be successfully negotiated. Indeed, the counsellors valued

the additional information the measures provided (e.g. a specific indicator of each individual

client’s level of risk regarding their alcohol use, smoking status and other drug use), as

evidenced by their updating their intake assessment forms to allow them to easily continue to

collect these additional data routinely.

177

In addition to the use of valid and reliable measures, the method of delivery of measures is

also important to consider for an evaluation. Computerised survey delivery has potential to

improve the efficiency of data collection and processing, for example by tailoring questions for

participants based on previous responses, providing instant feedback, and automatically

extracting data into computerised statistical computer programs for analysis (Bonevski et al.

1997). Further, computer programs can include verbal versions of survey questions to assist

participants with low literacy (Newell et al. 1997), which is applicable for Indigenous

Australians who have lower literacy levels than non-Indigenous Australians (Australian

Government 2013). The use of computerised surveys minimises missing data and achieves at

least comparable reliability and validity to pen and paper surveys or interviews (Bonevski et al.

1997; Newell et al. 1997). The use of computers to present surveys has also been shown to be

acceptable to clients in health care settings (Shakeshaft, Bowman & Sanson-Fisher 1998;

Bonevski et al. 1997; Newell et al. 1997). With new Tablet technology (e.g. Apple iPads), using

computers to present surveys is easy because of the convenient travel size and the novelty of

Tablet use with participants. Tablet use to deliver surveys could provide benefits to

researchers and participants, and when appropriate, could be considered for evaluating

interventions, although the acceptability of their use to health care providers and Indigenous

Australians should be assessed prior to their routine use.

Principle 3: building capacity to ensure the delivery of effective interventions is

sustained beyond the timeframe of the research project

Building capacity in health care services involved in the development, implementation and

evaluation of Indigenous-specific interventions can help ensure that the delivery of effective

interventions to Indigenous Australians is sustained beyond the timeframe of the research

project. This doctoral project, for example, demonstrated that it is feasible in the context of

178

routine health care service delivery, to provide benefit beyond the life of the research project

(Paper 3 (Calabria et al. submitted-a)). Key factors to facilitate this were that: 1) a local training

program was established to build the intervention skills of health care providers; 2)

intervention components and standardised delivery was documented (e.g. an intervention

manual written for the intervention context in consultation with health care providers); 3)

regular local supervisory meetings were organised to provide support for health care

providers; and 4) referral pathways into the intervention were established and transparent.

Nevertheless, a key challenge to sustaining interventions in routine health care service delivery

is that Indigenous health care has historically been under-funded (Allison, Rivers & Fottler

2004; Gray et al. 2010), resulting in low numbers of health care providers and a high turnover

of staff. Under staffing creates additional challenges when health care providers are asked to

incorporate research methods into their usual practice. Health care providers, who are already

busy, have previously identified that they perceive that they do not have the time to add to

their workload, nor the skills to address additional health issues that might be identified

(Shakeshaft & Frankish 2003; Solberg, Maciosek & Edwards 2008).

One way to address these challenges could be for supervisors and managers to discuss with

health care providers how they can best deliver health care services and incorporate research

methods into their routine workload. High staff turnover means that training health care

providers to deliver the tailored interventions needs to be ongoing to ensure that new staff

have the opportunity to deliver the intervention. It is therefore important to establish local

training programs that are sustainable over time: organising specific training days can provide

time free from competing tasks that is dedicated to intervention training. To facilitate this

process, this doctoral research found that the appointment of a nominated individual based at

the health care service who was specifically responsible for managing the intervention within

179

that service was instrumental to its successful implementation (see Paper 3 (Calabria et al.

submitted-a)). This finding reflects earlier health care service research which shows that

advantages of engaging a respected and influential study champion to promote new

interventions and problem solve issues as they arise (Fiore, Keller & Curry 2007; Ziedonis et al.

2007). The nominated individual can motivate health care providers to co-ordinate additional

intervention procedures into their routine practice. The nominated individual can also discuss

with health care providers their client outcomes, in a simple, comprehensible format at regular

intervals, which has been shown to improve the frequency and quality of their delivery of

clinical care (Barker 2000).

Another potential solution to the problem of integrating research into routine delivery of

health care services that has emerged from this research is to apply the same intervention to

multiple issues, where appropriate, to avoid health care providers having to learn multiple

intervention approaches. The CRA and CRAFT interventions, for example, have been used with

other population groups to address problem drug use (Roozen, de Waart & van der Kroft 2010)

and so, if the need is identified, it is likely that these programs could also be used to address

Indigenous drug use.

Conclusions

This thesis demonstrates a process of researchers working in partnership with health care

providers and with Indigenous Australians to tailor interventions for delivery to Indigenous

Australians through routine health care. It shows how the specific skills and expertise of

different groups can be combined: research skills in reviewing evidence and designing

evaluations and outcome measures; health care provider experience of working with

Indigenous Australians and skills in implementing interventions; and the knowledge and

expertise of Indigenous Australians in determining the type and format of interventions, as

180

well as highlighting new areas of concern. Three guiding principles are proposed for tailoring,

implementing and evaluating Indigenous-specific interventions: 1) consultation between

researchers, health care providers and Indigenous Australians is required from intervention

identification and modification, through to implementation and evaluation; 2) finding a

balance between methodologically rigorous research and intervention implementation in a

real world setting; 3) building capacity to ensure the delivery of effective interventions is

sustained beyond the timeframe of the research project. Specifically, health care providers and

Indigenous Australians should be actively involved in research projects aimed at tailoring,

implementing and evaluating Indigenous-specific interventions, and should work with

researchers to incorporate Indigenous Australian values and needs into routine service

delivery, using rigorous research methodology. This process requires compromise and

negotiation among researchers, health care providers and Indigenous Australians, as well as

confidence and trust that all those involved have improving the health and wellbeing of

Indigenous Australians at the forefront of decisions made. Local training and supervisory

programs should be overseen by a nominated individual, with the goal of maintaining

motivation among health care providers for training in intervention delivery, implementing the

intervention, collecting outcome data, and driving the intervention. Although these guiding

principles are the result of research into family-based intervention aimed at reducing alcohol-

related harm among Indigenous Australians, they are likely to be applicable to the evaluation

of a wide-range of Indigenous-specific interventions.

181

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Appendices

216

Appendix A

Search strings for systematic search for family-based alcohol interventions

Database Search group Search terms

EMBASE# Alcohol Alcohol or ethanol

exp alcohol OR exp alcohol consumption OR exp alcohol

intoxication

Intervention Intervention or therapy or psychotherapy or treatment

exp intervention study exp family therapy or exp

psychotherapy or treatment outcome

Family Family and parent

exp family or exp family counselling or exp family interaction

or exp family study or exp parent

ERIC Alcohol Alcohol or ethanol

Intervention Intervention or family intervention

Family Family or parent or family relations

Family studies

abstracts**

Alcohol Alcohol or ethanol

Intervention* Intervention or family intervention

Family* Family or parent

Indigenous

Australian

Alcohol and

Other Drugs

Bibliographic

Database

Alcohol Alcohol

Intervention Interventions

Family

Australian

Indigenous

HealthInfoNet

Alcohol Alcohol

Intervention Intervention

Family Family

Medline Alcohol Alcohol or ethanol

exp alcohols or exp ethanol

Intervention Family intervention or intervention

exp family therapy or exp intervention studies

Family Family or parent

exp family or exp family relations or exp parents or exp parent

217

Project CORK

Alcohol Alcohol


Family Family

Proquest Social

Science Journals

(search “citation

and abstract”)

Searched

“subject”




PsycINFO

Alcohol Alcohol OR ethanol

exp alcohols OR exp ethanol

Intervention Intervention OR family intervention

exp intervention or exp family intervention


exp family relations or exp family therapy or exp parents

Sociological

abstracts

(search

“keywords”)




Web of Science

Alcohol alcohol or ethanol

Intervention intervention or family intervention or family-based intervention

or family-focused intervention

Family family or parent

218

Appendix B

Formulae for analysis

Formulae

Sensitivity a / a + c True positive / Condition present

Specificity d / b + d True negative / Condition absent

Positive predictive value a / a + b True positive / Positive test

Negative predictive value d / c + d True negative / Negative test

Explanation of Symbols

Condition present Condition absent

Positive test True positive [a] False positive [b]

Negative test False negative [c] True negative [d]

Note. Adapted from (Lemeshow et al. 1990).

219

Appendix C

Health care provider consent form

Yoorana Gunya Family Violence

Healing Centre Aboriginal

Corporation

Condobolin Aboriginal Health

Service

Information for Participants: Health Worker

Name of research project

The cost benefit of a Community Reinforcement and Family Training (CRAFT) alcohol

intervention for Indigenous Australians.

What is the project?

We are trialling two alcohol programs for Aboriginal people. Program One, The Community

Reinforcement Approach (CRA), is a program of counselling and support to help Aboriginal

people who drink too much alcohol to cut down or stop drinking. Program Two, Community

Reinforcement and Family Training (CRAFT), is a program of training and support for family

members and/or friends of Aboriginal people who drink too much alcohol. Both programs will

be delivered by workers from Yoorana Gunya Family Violence Healing Centre Aboriginal

Corporation (Forbes) and the Lyndon Community (Orange). The National Drug and Alcohol

Research Centre (NDARC) at the University of New South Wales (UNSW) will work with

Yoorana Gunya and Lyndon Community to assess how well both programs work.

What it means to be a part of the Community Reinforcement and Family Training (CRAFT)

alcohol intervention project?

If you agree to be part of the project you will be asked to participate in professional

development training to provide you with the knowledge and skills you need to deliver the

Community Reinforcement Approach (CRA) or Community Reinforcement and Family Training

(CRAFT). If you are trained and/or certified in CRA you will be asked to deliver the program to

clients who have alcohol problems and have agreed to participate in the project. If you are

trained and/or certified in CRAFT you will be asked to deliver the program to clients who have

220

a relative/s with alcohol problems and have agreed to participate in the project. You will also

be asked to participate in interviews after you have completed training and/or certification.

Interviews will be held at Yoorana Gunya Family Violence Healing Centre Aboriginal

Corporation and/or at the Lyndon Community, and will take up to one hour. The interviews

will be conducted by a researcher involved in the project. The researcher will ask you

questions about your experiences completing the training and certification programs. All

interviews will be audio taped. You may also be asked by researchers to provide access to your

outreach diary so researchers can gain information about how much time is required to

provide outreach services. Brief access to your diary will only be required at a time that is

mutually suitable for the researcher and the worker.

Name, address and telephone number of principal researcher, for the purposes of this

document, unless otherwise stated, also called the Data Custodian

A/Prof Anthony Shakeshaft



Sydney NSW 2052 Australia

Phone: 02 9385 0285, or Email: [email protected]

Name, address and telephone number of institution, for the purposes of this document,

unless otherwise stated, also called the Data Repository.


Faculty of Medicine


Sydney NSW 2052 Australia

Phone: 02 9385 0333, Fax: 02 9385 0222

Right to withdrawal

Participation is voluntary. At any time you can choose not to be a part project and may ask for

the information that you have given not to be used. Withdrawing from the project will not

result in any personal or financial penalty to you. Taking part in the CRAFT Project is not a

condition of your employment.

Confidentiality and privacy

Any information you give will be private and confidential and will not be used in any way that

will identify you. All data will be stored in secure facilities, and accessed only by authorised

personnel for up to seven years, after which it will be destroyed. Specific information about

you will not be published in a manner that could identify you as an individual, during or after

mailto:[email protected]

221

the conclusion of this project. Published information may identify Yoorana Gunya Family

Violence Healing Centre Aboriginal Corporation and the Lyndon Community.

Potential risks and discomforts

As part of the CRA and CRAFT programs you will need to ask sensitive questions that may

result in psychological distress experienced by your client or by yourself. You will be provided

with training on how to ask sensitive questions and respond accordingly. If you experience

psychological distress specialist counsellors, mental health workers and medical addiction

specialists will be available to provide additional advice and support.

Community consultation

The Aboriginal community, through the representative members of the board of Yoorana

Gunya Family Violence Healing Centre Aboriginal Corporation, Orange Aboriginal Medical

Service and Lyndon Community has been consulted and agreed to be a part of the CRAFT

project.

Ethical provision

The CRAFT project abides by ethical conduct relating to health research in Aboriginal

communities as stated in National Aboriginal Community Controlled Health Organisation

(NACCHO), Aboriginal Health & Medical Research Council (AH&MRC), National Health &

Medical Research Council (NHMRC), UNSW ethics publications, and the Human Research Ethics

Committee (HREC) of the Greater Western Area Health Service and that, where required,

ethics approval has been granted by these organisations.

Questions and concerns

If you have any questions about the CRAFT project you can contact the principal researcher

listed on page 2. If you have any complaints you should contact the three ethics committees

listed below:

The Chairperson

AHMRC Ethics Committee

PO Box 1565

Strawberry Hills NSW 2012

Phone: 02 9212 4777

Fax: 02 9212 7211

Email: [email protected]

UNSW Ethics Secretariat


Sydney 2052 AUSTRALIA

Phone: 02 9385 4234

Fax: 02 9385 6648


The Executive Officer

Greater Western AHS

HREC

PO Box 143

Bathurst NSW 2795

Phone: 02 6339 5601



222

Health Worker Consent for the CRAFT project

I, ................................................................................................................ [print full name], have

read and understood the Information for Participants: Health Worker.

I have been made aware of the procedures involved in the study, including any known or

expected inconvenience, risk, discomfort or potential side effect and of their implications as

far as they are currently known by the researchers. I understand that I can withdraw my

participation from the study at any time.

I hereby agree to participate in this research study.

Signature of participant: Date:

Witnessed by [print name]:

Signature of Witness: Date:

223

Appendix D

Qualitative data analysis

Memos: Working group meeting notes data

1. Literacy issues working with Aboriginal clients so keep language simple.

2. 4-6 sessions max

3. Certification helpful, in addition to training day (good supervision, designated days for

CRAFT have been good)

4. Problems with asking family member why a drinker is behaving in a certain way

5. Problem with fit of US training (where their language must be used) and real world

delivery to Aboriginal clients (language needs to be changed).

6. Resources good but language needs to be simplified

7. Delivery of CRAFT and CRA in groups (rather than individual)

8. Shorter package of outcome measures

9. Recruitment options: probation and parole and other health care services

224

Code Book: Working group meeting notes data

Code Description

CRAFT certification

(CERT)

Usefulness of the CRAFT certification process

Therapeutic issues

(THERA)

Problems with aspects of the therapeutic approach

Adapt CRA and CRAFT

(ADAPT)

Information about adapting CRA and CRAFT to be` appropriate for


Measures (MES) Information about modification to outcome measure

Recruitment (RECRUIT) Information about possible referral pathways

225

Data Display Matrix: Working group meeting notes data

ID Working group

meeting A

Working group

meeting B

Working group

meeting C

Working group

meeting D

Working group

meeting E

Working group

meeting F

Working group

meeting G

CERT “Workers agree

that(certification)

has been helpful

in addition to the

training days”

(p.1)

“Good to be

recorded and

have

feedback...supervi

sion has been

great...role plays

are good even

though stressful

because you can

see how others

work as well...no

problems with

procedures...desig

nated days for

CRAFT have been

good” (p.1)

THERA There is a problem

with asking a

family member

“asking family

members to make

concessions to the

226

ID Working group

meeting A

Working group

meeting B

Working group

meeting C

Working group

meeting D

Working group

meeting E

Working group

meeting F

Working group

meeting G

what their relative

is thinking or

feeling...don’t

want the family

member to feel

responsible for

the drinker’s

behaviour” (p.3)

drinker (is a

challenge) and

asking the family

member to talk

about whey they

thing the drinker

is behaving in that

way” (p.1)

ADAPT “In practice, it

needs to be basic”

(p.12)

“...the manual will

have a basic

outline of what

can be included in

the sessions...then

the worker tailors

it to the client”

(p,16)

“...something to

take and

something to

refer to...not too

detailed...more of

a guideline” (p.23)

“eight sessions is

too many...” (p.2)

“...change

language...” (p.3)

“...will have to

change the

language...to be

more appropriate

when working

with clients” (p.1)

“Workers would

like a checklist

that follows the

US trainer’s

structure but

change to more

appropriate

language for

Aboriginal health

care” (p.2)

Happy with

tailored resources

that reflect the

“resources may be

changed for low

literacy...” (p.2)

CRA and CRAFT

will be delivered

in a group setting,

as well as offered

individually (p.2)

227

ID Working group

meeting A

Working group

meeting B

Working group

meeting C

Working group

meeting D

Working group

meeting E

Working group

meeting F

Working group

meeting G

original CRAFT

resources but

have language

changed (p.3)

“As the project

progresses case

studies from real

clients should be

added to the

manual to be used

for future

training” (p.2)

MES “Overall (outcome

measures

package) needs to

be shorter, not

repetitive, and

remove parts that

don’t appear to be

relevant” (p.2)

RECRUIT Possible referral

pathways were

identified:

probation and

parole, other

health services,

other Aboriginal-

228

ID Working group

meeting A

Working group

meeting B

Working group

meeting C

Working group

meeting D

Working group

meeting E

Working group

meeting F

Working group

meeting G

specific services

229

Memos: Interview data

1. Language changes required

2. Good structured program but prescribed sessions not practical

3. Role plays critical/useful to cement training even though uncomfortable at first

4. Ease of Skype and ooVoo use

5. Resources good

6. Manual - Not used - Use – scenarios were good

7. Training intense but useful

8. Time constraints and other commitments for audio taping sessions, no time constraints for

supervision

9. Supervision positive and needed for motivation

10. Team member support important

11. CRAFT is adaptable to Aboriginal Australians

12. Function analysis – not right to ask someone what they think someone else is feeling

13. Training in Indigenous specific

14. Need experience working with Aboriginal Australians to give comment on changes to

CRAFT

15. Don’t need a degree to be a therapist but do need experience

16. Complex clients don’t fit with original CRAFT

17. Training fostered personal growth

18. Happiness scale and positive communication skills both useful

19. Positive reinforcement for drinker hard for family member to do

20. Similar to what done/doing before/now

21. Role plays for certification – didn’t always work with the same partner

22. Obstacle – role plays and recordings but people got use to it

23. Training pitched fine but need a level of counselling experience

230

Code Book: Interview data

Code Description

CRAFT Certification

(CERT)

Usefulness of CRAFT training days and CRAFT certification INCLUDE

information about experiences during role plays

CRA Training (TRAIN) Usefulness of CRA training day

Therapeutic issues

(ISSUES)

Issues raised with the training and delivery of CRA and CRAFT

Organisational support

(SUPPORT)

Therapist supervision, team member support, supervision sessions

with the U.S. supervisor

Qualifications of

therapists (QUALS)

Information on the pitch of training and what qualifications would

be appropriate for health workers interested in doing CRAFT

certification

Adaptability of CRA

and CRAFT for


(ADAPT)

Adaptability of CRAFT for Aboriginal Australians INCLUDE

information about changes required to language to be appropriate

for Aboriginal Australians INCLUDE statements about the manual

and intervention resources (e.g. Functional Analysis, Happiness

Scale, Positive Communication, etc.)

231

Data Display Matrix: Interview data

ID Health care provider

101

Health care

provider 102

Health care

provider 103

Health care

provider 104

Health care provider

105

Health care

provider 106


107

CERT “I’m actually quite an

advocate for it now

and particularly with

the tools like with the

happiness scales and

with things like that,

that’s something that

really people can look

at and they can see

where they’ve

changed and made

progress and things

that they really want

to look at and things

like that.” (p.17)

“I think it was all

really good, I wouldn’t

change anything, I

don’t think.(p.19)

“Doing the role-plays

and talking to (the

supervisor) there a

couple of weeks ago

was really good”

(p.17)

“I tried not to do the

role plays...but it was

“...at first it was a

bit overwhelming”

(p. 8)

“...I liked the fact

that it had...some

group work...gave

the opportunity

to...getting the

concept of

(CRAFT)” (p. 9).

“...having an open

discussion with

the other people

who were in

training for the

supervision (was

useful)” (p.10)

“...doing some role

playing during the

workshops, I think,

was valuable for

people to

understand the

concept rather

than being talked

at” (p. 8)

“...we had a few

“...enjoyed the

CRAFT training, I

thought it was

really good”

(p.3)

“(the workshop

format) was a

little bit dated”

(p. 4)

“...(the

accreditation

process has)

been really,

really valuable

for the people

who have gone

through it to get

feedback about

their skills in

counselling,

regardless of

doing the

procedures

which are part

of the program”

(p.11)

“I thought that

“It was really

good to have -

see the role play

and do a reverse

role play and

that sort of

thing...” (during

Skype

supervision

sessions) (p.7)

I think (the

audio-taped

sessions) was a

kind of a tough

process to start

with... I was not

quite sure if I

was doing things

right... I

found...it really

good to get back

the feedback”

(p.11)

“To start with, it

was tricky ‘cause

... co-ordinating

time and getting

Oh, (the workshop

with the US trainer)

was good...I really

enjoyed it” (p4)

“...(Skyping with the

US supervisor) was

excellent...really,

really good...” (p.5)

“...I just found it

really, really good,

and just the support

that the US

supervisor’s given

us, fantastic.

Difficult in getting

my old head to think

in a different way

with some of the

procedures, so I did

send off a few tapes

where I just didn’t

get it, but then I’ve

got it, if you know

what I mean? “ (p.4)

“I’ve learnt more

from talking to the

US supervisor

“I thought the

workshop was

good... that

made it sort of

sink in a little bit

better than if we

had of just gone

through the

information but

yeah, I thought

it was good

training” (p.4)

“We just found

it really draining

to be – because

it was so

structured” (p.7)

“I actually found

(Skyping) pretty

useful” (p.4)

“Like I guess

ideally it would

probably be

better to be able

to do

(supervision) in

person but there

“...the actual content

was good (of the

workshop)...nothing

really that I hadn’t

done before, but it

was just packaged

differently” (p.4)

“the whole process

has been good for

everybody, I think”

(p.17)

“I can’t really think of

anything negative

about the training.

It’s good for people to

get that feedback on

the counselling, too”

(p.24)

“...(Skyping) was very

good, I thought... he

gave us a lot of good

feedback... he’d

demonstrate...the

difference ways of

asking people and

that sort of stuff”

(p.5)

232


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

good watching how

he (the supervisor)

...approached stuff”

(p.5)

“I think the Skype

concept was definitely

a recommendation

that I would put in to

support people who

are doing this

training” (p. 9)

“think it was fantastic

that we had the

Skype” (p.16)

technical issues

(with Skype)...but

on the whole it

worked really well

and I was quite

surprised actually

how well it did

work” (p.4)

(supervision on

Skype) was a

very useful tool,

rather than

reading. I think

it was good

because you

could then ask

questions

directly” (p.9)

“I thought

(recording

sessions and

getting

feedback) was

excellent

because you’re

actually getting

a feedback from

each time you

do a tape...it’s

helping you...to

make sure you

are on the right

track” (p.14)

“(the supervisor

is) a very good

supervisor” (p.5)

So we had a few

online. And we

work out of a

car. And so it’s

kind of - yeah, it

was a bit tricky.

But when I was

in the office and

able to sort of

connect and

participate in

those sessions,

they were really,

really good”

(p.7)

Skyping, and then

for him to analyse

our tapes (compared

to reading the

books)” (p.7)

Skyping wasn’t

(difficult)...the

technology I found

(difficult) was

loading (audio-

recordings) on the

computer and

sending it to the US

supervisor” (p.5)

wasn’t ever a

time that I

thought, this is

really hard

because he’s on

the other side of

the computer”

(p.5)

“To start with,

(the technology)

was a little (bit

of an issue) but

once we

changed to

Oovoo it

seemed to have

sorted out a bit

better” (p.5)

“People generally

don’t like (role plays),

but it’s a good way of

doing the training, to

involve people more”

(p.5)

“I think we only had

glitches a couple of

times (with Skype)”

(p.6)

233


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

technical issues

(with Skype)...

but on the

whole it worked

really well and I

was quite

surprised

actually how

well it did work”

(p.5)

“... we would

not have had so

many people

accredited and

we would not

have been able

to do it so

quickly (without

doing role plays

for the

accreditation

sessions)” (p.7)

TRAIN -- -- “For those of us

who had done

CRAFT, we

found the first

day (of CRA

training) a little

boring because

“...recently done

the CRA

training, which

was fantastic...”

(p.23)

-- “(CRA training)

was good....a lot

of it was stuff I

found very

useful and have

started using

little bits and

234


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

it was talking

about functional

analysis and

that sort of

stuff...but the

second day, we

did quite a few

more exercises

and ...some

group stuff

(p.15)

pieces with

clients already

when I’ve been

talking to them,

so that’s good”

(p.17)

ISSUES “I only did a few

(supervision sessions)

because they were on

Thursday...” (p.5)

“what was good for”

me personally, is

when we had

identified CRAFT days

because sometimes

fitting it in was

difficult...and that

really motivated all of

us, I think, to just get

stuck in” p.8)

“...(role playing) was

excruciating but it was

really good. It was

good putting it in

Didn’t look at

manual “mainly

due to time

restraints” (p.10)

“sometimes you

didn’t want to do

the sessions,

mainly because of

overload from

other areas of

your work” (p.15)

“Some sessions I

missed because I

was committed to

other things”

(p.19)

“...it really was a

significant time

and effort

commitment for

the last 10

months” (p.5)

“I’d always

learnt in

counselling that

you don’t get

people to

theorise or

hypothesise

about how

someone else

feels...it was a

different spin

when...you ask a

“I mean the

negatives was

the time and the

pressure that it

put on you”

(p.15)

“...it was kind of

hard to do (role

plays) and feel

natural about

it...the more we

did it, the more

you got used to

that (p.11)

“(the certification

process) was

challenging...fitting

it in with work” (p.8)

“....(role plays with

other therapists

was) a bit

confrontational in

that you’re seeing

another therapist

see your style and

then you wonder if

that’s okay, if you’ve

done okay, am I

doing it okay” (p.8)

“The hardest

part of it was

finding the time

to get (the role

plays) done”

(p.7)

“I am a lot more

confident with

using it now

than I would

have been if we

hadn’t have

done the role

plays before and

just getting the

feedback was

good to know

this bit you did

“The worst part was

trying to get everyone

motivated to do (the

audio-taped

sessions), and actually

co-ordinating them all

to actually do them.

So we set aside days –

specific days – to get

a couple done each of

those days. And that

worked well because

everybody could just

concentrate on that.

So I thought it was

good, especially

because I was

listening to other

235


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

practice.” (p.8)

woman ...when

you are doing a

functional

analysis...how

do you think he

feels?” (p.11)

really well, this

bit you probably

need to work

on” (p.8)

“...so I think

trying to get

people to really

look at their

family member’s

behaviours and

trying to reward

them and things

like that, might

be a bit tough...

And I think the

difference

between trying

to get people to

understand

between

positive

reinforcement

and enabling

that is going to

be pretty tricky

as well... (time

out for positive

reinforcement)

has the potential

people, so I could see

where their skill level

was at, and that sort

of thing. So it was a

good learning curve

for, yeah, everybody.”

(p.8)

236


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

to be pretty

tricky as well”

(p.13)

SUPPORT “...prompting from

health care provider

107, like – you can do

this, and you can do

this and all that sort

of stuff, yeah. Just

her support was really

good and the

supervision and

everything, yeah”

(p.20)

“(organisational

support) did

(make a

difference)

because we were

all doing it

together...” (p.15)

“getting the

feedback within a

short period of

time, I think, is

really important

because that’s

making you take

ownership as a

practitioner of this

program and also

making sure that

you’re rolling it

out within the

context of how it

should be

presented” (p16)

“Well health

provider 107’s

been great. So

as the manager

of the Outreach

team, if she

hadn’t

encouraged and

sometimes

insisted that her

staff participate

then we

wouldn’t have

had such a good

group – a good

result with the

accreditation”

(p.8)

“It was really

good to sort of

work in a team

that was doing it

together

(p.12)... we sort

of kept pushing

each other along

and we needed

to keep going

with it, because

we were all

doing it

together” (p.13)

“...(organisational

support has) been

great” (p.10)

“Health care

provider 107

was really, really

good with it. I

don’t think we

would have got

it done if she

didn’t actually

push us to do it”

(p.8)

“...having everybody

sorted together and

just keeping (CRAFT

certification) as a

topic of conversation

in the office, and

keeping it live, if you

like, was good” (p.10)

“...it was good having

health care provider

103 involved,

too...having someone

external to the

team...that’s still part

of it, to help drive it a

bit” (p.11)

QUALS “(pitched right)...yes”

(p.5)

“I think that

there’s quite a

lot of high level

“...so long as

you had those

people skills and

237


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

practice

required to

implement

CRAFT in the

way that it’s

intended...I

think people will

vary in the way

they implement

the procedures”

(p.12)

sort of the

willingness to

sort of learn

something

different, and

then to apply it.

Sometimes I

think there’s

some resistance

to apply it,

maybe from

some lack of

confidence. But

that’s - I think

that’s more

down to an

individual,

rather than their

level of

knowledge and

experience...

sometimes

probably

experience is a

more useful

thing than

having the

university

education”

238


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

(p.25)

ADAPT “... I think we all had a

bit of avoidance there

initially but once it

was set in concrete

we were fine.” (p.9)

“...it’s very broad, it

can be used for lots of

different... in day to

day stuff for people to

learn to communicate

and things like that’s

been really good...

And getting them to

think about things a

bit differently, think

outside of the

square.” (p.10)

“I think the wording of

(the functional

analysis) might be

difficult... (p.13) it’s

just a big ‘jawbreaker’

Aboriginal people

would call that” (p.14)

“...giving (the client)

something they can

relate to” (p.14)

“...because this is

a project for the

Indigenous, I think

it may be too

structured but we

won’t really know

until we actually

start that” (p.8)

“some of the

language, I think,

needs to be sort of

maybe looked at”

(p16)

“maybe use some

pictures” (p.17)

“...you’re working

with people who

live in these

worlds of chaos,

you’ve really got

to look at the

language so that

everyday people in

that country can

relate to it. So I

think it really

needs to be - an

“With (the US

trainer’s) style

of presentation

was even less

appropriate for

aboriginal

people with

maybe minimal

experience

maybe” (p. 4)

“My biggest

concern...is

whether people

(clients) keep

coming back”

(p13).

“The happiness

scale just seems

a bit ‘70s to me”

(p.14)

“when I started

doing a

functional

analysis...using

that to ask what

another person

thought that the

other person

might be feeling,

I found that

quite strange. I

found that quite

a difficult thing

to be asking of

somebody. And

it just - yeah, it

didn’t seem

right

therapeutically

for me to be

asking” (p.16)

“So I find using

this kind of

model, an

American

model, for an

indigenous

“some of the

wording needed to

change” (p.15)

“...(CRAFT

procedures) can be

adapted (for the

Indigenous context)

(p.17)... you might

need to tweak it a

little bit” (p.19)

“The Functional

Analysis, took a little

bit of time to get my

head around that”

(p.14)

“...if I was

actually doing it

with a family I

wouldn’t use

those terms”

(p.9)

“language that

is used I think I

probably just

wouldn’t use it”

(p.16)

“...(the manual)

made it a lot

easier to

understand

what each

component

was” (p.6)

“I think the

happiness

scale’s really

good; I think

that’s definitely

something that

we could use

quite easily with

people. I think

“...we’re going to

have to modify

(CRAFT) a bit

for...Australia, for the

clients...just the

wording and that sort

of stuff” (p.14)

“Yeah, overall, it’s a

good idea.

Particularly the

positive

communication skills,

which help the

counsellors as well.

Yeah, I think it’s all

pretty good. But it’s

just adapting it, is the

main thing” (p.16)

“I think the number

of sessions would be

limited. You’d

probably get up to

four to six. Six at a

push.” (p.16)

“...the scenarios out

of the manual... were

good” (p.7)

239


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

“The language...as it is

written, might need to

be broken...maybe

just simplified” (p.15)

“I think it’s all doable

with the Aboriginal

community, it’s just

that the language

might just need to be

adapted a little bit to

suit them a bit better”

(p.15)...tweak then

here and there for the

individuals” (p.17)

“The language used

definitely needs to be

different and just a

little bit simplified or

it needs to be put in

Aboriginal language

and I don’t mean a

dialect I mean in the

way Aboriginal people

speak English” (p.17)

“I’m sure it can be

adapted. In its

present probably

form, it might be a bit

daunting for

Australian version

of it really needs

to be looked at.

The concepts are

still the same but

again, you need to

look at it in a

different way”

(p.23)

“(with Indigenous

people)... you

really need to look

at what’s

happened to them

in the past, how

would you present

this, because if

anything looks

government-like,

word-like, they

shut down, which

you can

understand” (p.

23)

“So you’ve really

got to do what we

call a soft entry

approach” (p. 24)

“...it was good to

population, it

doesn’t quite fit

with me at the

moment” (p.17)

“...so yes,

there’s

components

within this

training, and

certainly that I

think will work

for Indigenous

people” (p.21)

“We’re going to

get the

opportunity to

now go out and

look at what will

and won’t work

about that. And

I think that’s a

great thing.

Yeah” (p.24)

“if we could sort

of take away

some of the sort

of more

American based

language” (p.26)

some of the

things like with

the functional

analysis, trying

to get an

understanding

of: what does

your loved one

think right

before he

drinks, or what

does he feel

right before he

drinks? I think

that’s going to

be pretty hard

for people and I

guess how

accurate that’s

going to be is a

bit of a concern I

think.” (p.11)

“I think they’re all

(resources)pretty

good” (p.14)

240


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

Aboriginal people but

if it can be adapted

and a bit more user

friendly for their

community I think it

will be a really good

program” (p.19)

“That was all really

good...the copies of

the happiness

scale...the

worksheets...all that

stuff...” (p.6)

“Yeah, they were

good, they were very

good because they

were concise and they

told you exactly what

you needed to do and

that was how I

identified my little

gaps, things that I

might have missed.”

(p.7)

“I like those pieces of

paper, they were

good. When we were

doing recordings I’d

have them near me –

read (the

PowerPoint

presentation

handouts)...to get

your head around

it” (p. 10)

“I really liked the

Happiness Scale, I

liked ...functional

analysis” (p.13)

“Happiness

Scale...maybe

have it sort of

different (terms)...

(p. 18)

“The Domestic

Violence

Precautions, I

thought that was a

good warning sign

because the whole

idea is not to make

the situation

worse for the

family.” (p. 20)

“that to me is

how I feel

comfortable

using CRAFT is

having an

Aboriginal

worker. Yeah,

yeah, yeah,

come along and

walk alongside.”

(p.27)

“...(the manual)

was great” (p.9)

“The manual’s

great” (p.10)

“I think the

functional

analysis is a

fantastic tool to

use say in the

CRA which I’ve

just done the

training on. And

I think that’s a

fantastic tool to

use directly with

somebody who

is using. But I

just - and I still

241


101

Health care

provider 102

Health care

provider 103

Health care

provider 104


105

Health care

provider 106


107

okay, I need to do this

now” (p.12)

“...it was hard doing

the rewarding the

positive

behaviour...and then

practicing the

withdrawing of

rewards...that was

tricky. The

communications stuff

was really...good. But

the consequences was

a bit tricky to get

them to understand”

(p.12)

have my doubts

about that with

CRAFT” (p.17)

242

Appendix E

CRA and CRAFT intervention resources

CRA Checklist Once you have completed a procedure with a client tick the appropriate box and write the

date the procedure was completed. The checklist should be added to after each CRA session.

Procedure

completed

Date/s procedure

completed

(dd/mm/yy)

Overview of CRA

1. Describe the basic purpose of CRA (e.g. help

find healthy, reinforcing lifestyle…)

2. Provide a brief overview of CRA procedures

3. Present positive expectations (describe scientific base)

4. Describe expected length of the CRA program

5. Ask drinker to identify their reinforcers

Functional Analysis of Drinking Behaviour

6a. Give drinker a reason for Functional Analysis

(wealth of info; behaviour worth examining)

7a. Ask drinker to describe a drinking episode

8a. Ask drinker to identify internal and external

triggers

9a. Ask drinker to specify drinking behaviour during drinking episode (drinks what, how much, over what time)

10a. Ask drinker to describe short term positive and

negative consequences of drinking

11a. Give drinker examples of how Functional

Analysis of Drinking Behaviour information will

be used

243

Functional Analysis of Non-drinking Behaviour

6b. Give drinker a reason for Functional Analysis


7b. Ask drinker to give general description

relative’s enjoyable, healthy non-drinking

behaviour

8b. Ask drinker to identify internal and external

triggers for enjoyable, healthy non-drinking

behaviour

9b. Ask drinker to specify relative’s enjoyable,

healthy non-drinking behaviour (what)

10b. Ask drinker to describe short term positive and

negative consequences of enjoyable, healthy

non-drinking behaviour

11b. Give relative examples of how Functional

Analysis of Non-drinking Behaviour

information will be used

Functional Analysis for Relapse

6c. Give drinker a reason for Functional Analysis


7c. Ask relative to describe a relapse episode

8c. Ask drinker to identify internal and external

triggers

9c. Ask drinker to specify behaviour during relapse

episode (what)

10c. Ask drinker to describe short term positive and

negative consequences of relapse behaviour

11c. Give drinker examples of how Functional

Analysis of Relapse Behaviour information will

be used

244

Sobriety Sampling

12. Explained what sobriety sampling is

13. Give drinker a reason for sampling sobriety (e.g., forces use of other coping strategies)

14. Decide on a time period for being sober

15. Develop a plan for staying sober at least until

next session

16. Develop a back-up plan for staying sober at

least until the next session

17. Remind drinker of positive reinforcers for

being sober

Happiness Scale

18. Give drinker a reason for the Happiness Scale

19. Explain how to complete the Happiness Scale

20. Discuss drinker’s responses to the Happiness Scale

Treatment Plan/Goals of Counselling

21. Use Happiness Scale to choose a goal category

22. Develop a goal (e.g. brief, positive, specific, reasonable, under control, based on skills)

23. Check on progress of previous goals

Communication Skills

24. Discuss reasons why communication skills are

important

25. Describe the 7 components of positive

communication

26. Give examples of good and inadequate

communication styles

27. Conduct a role play and provide feedback;

repeated

28. Conduct a reverse role play

Drink Refusal Skills

29. Enlisted social support

30. Discuss high-risk situations

31. Discuss options for drink refusal (e.g. changed subject)

32. Conduct a role play and provide feedback; repeated

245

Problem Solving Skills

33. Describe problem solving steps

34. Conduct CRA problem solving procedure (e.g.

define the problem, brainstorm)

Social/Recreational Counselling

35. Discuss how important it is to have a satisfying

social life

36. Decide on an area of social life to improve (e.g.

through problem solving)

37. Discuss and plan how to include a new

enjoyable behaviour/activity in the drinker’s

life

Systematic Encouragement

38. Identified need for systematic encouragement and took first step in session (e.g. make a call)

39. Discussed systematic encouragement in following session

Relapse Prevention

40. Complete Functional Analysis for Relapse

41. Discuss relapse behaviour as a chain of events

42. Describe and set up early warning system

Miscellaneous

43. Discussed reinforcers

44. Monitor triggers

45. Check for use of skills across situations

46. Assigned homework

47. Reviewed homework

48. Conduct a role play and provide feedback; repeated

49. Used only the CRA objectives and procedures

50. Introduced CRA procedures at appropriate times

Adapted from (Meyers & Smith 1995)

246

CRA Functional Analysis of Drinking Behaviour External Triggers Internal Triggers AUDIT-C Short-term positive consequences Long-term negative

consequences

When you drink

who are you

usually with?

Where do you

usually drink?

When do you

usually drink?

What are you usually

thinking about right

before you drink?


feeling physically right

before you drink?


feeling emotionally

right before you

drink?

How often do you drink?

When you drink, how

many do you usually

have in one day?

How often do you have

six or more drinks on

one day?

What do you like about drinking with … (whom)?

What do you like about drinking at … (where)?

What do you like about drinking … (when)?

What are the negative results

of your drinking in each of

these areas?

Interpersonal

Physical

Emotional

Legal

Work/study

Financial

Other


247

CRA Functional Analysis of Non-drinking Behaviour External Triggers Internal Triggers Behaviour Short term negative consequences Long term positive

consequences

Who are you usually with

when …(behaviour/activity)?

Where does you

usually…(behaviour/activity)?

When does you usually

…(behaviour/activity)?



before



feeling about right

before


What is the non-

drinking

behaviour/activity?

How often do you

usually do it?

How long a period

does it last?

What do you dislike about ... (behaviour) [with

whom]?

What do you dislike about ...(behaviour) [where]?

What do you dislike about ...(behaviour) [when]?

What are some of the unpleasant thoughts you

usually have while ...(behaviour)?

What are some of the unpleasant physical feelings

you usually have while ...(behaviour)?

What are some of the unpleasant emotional

feelings you usually have while you are

...(behaviour)?

What are the positive

results of ...(behaviour) in

each of these areas?

Interpersonal

Physical

Emotional

Legal

Job/study

Financial

Other


248

CRA Functional Analysis of Relapse Drinking Behaviour External Triggers Internal Triggers Behaviour Short-term positive consequences Long-term negative

consequences

Who were you with

when you drank?

Where were you

when you drank?

When did you

drink?

What were you

thinking right before

you drank?

What were you

feeling physically right

before you drank?

What were you

feeling emotionally

right before you

drank?

What were you

drinking?

How much did you

drink?

Over how long a period

of time did you drink?

What did you like about drinking with … (whom)?

What did you like about drinking at … (where)?

What did you like about drinking … (when)?

What are some of the pleasant thoughts you had while

you were drinking?

What were some of the pleasant physical feelings you

had while you were drinking?

What were some of the pleasant emotional feelings

you had while you were drinking?

What were the negative results

of your drinking in each of

these areas?

Interpersonal

Physical

Emotional

Legal

Work/study

Financial

Other


249

CRAFT Checklist Once you have completed a procedure with a client tick the appropriate box and write the

date the procedure was completed. The checklist should be added to after each CRA session.

Procedure

completed

Date/s procedure

completed

(dd/mm/yy)

Initial Meeting Motivation Strategies

1. Enable family member to express feelings and

thoughts

2. Ask family member to describe their relatives

alcohol use and its effects

3. Demonstrated an understanding of the problem

4. Discuss family member’s motivation to help

relative

5. Begin to identify problem areas

6. Provide a brief overview of CRAFT principles

(problem-focused; skills based; role-plays;

assignments)

7. Present positive expectations (7/10 family

members; variety of relationship and drugs; client

feels better)

8. Describe the CRAFT goals

9. Provide a brief overview of CRAFT procedures

10. Briefly explain reason for involving family

members in CRAFT & positive expectations

11. Outline family member responsibilities

12. Outline issues of confidentiality

13. Review baseline measures

14. Ask family member to identify their reinforcers

250

Domestic Violence Precautions

15. Use non judgmental approach to ask family

member about family violence

16. Ask family member about & assesses level of

violence

17. Discuss available support

18. Assess need for additional support

19. Decided if more support is needed

20. Enable family member to express feelings and

thoughts

21. Discuss triggers or “red flags” for their relative’s

violent behaviour

22. Discuss family member’s personal safety

23. Discussed how the family member can protect

themselves at their home (have a bag packed?)

24. Discuss safe responses to possible family violence

e.g. women’s refuge, extended family/friends

25. Discuss legal options e.g. AVO

251

Functional Analysis of Drinking Behaviour

26a. Give family member reason for Functional

Analysis (wealth of info; family member

behaviour worth examining)

27a. Ask family member to describe a drinking

episode

28a. Ask family member to identify internal and

external triggers

29a. Ask family member to specify drinking behaviour

during drinking episode (drinks what, how much,

over what time)

30a. Ask family member to describe short term

positive and negative consequences of relative’s

drinking

31a. Give family member examples of how Functional

Analysis of Drinking Behaviour information will

be used

Functional Analysis of Non-drinking Behaviour

26b. Give family member reason for Functional



27b. Ask family member to give general description

relative’s enjoyable, healthy non-drinking

behaviour

28b. Ask family member to identify internal and

external triggers for enjoyable, healthy non-

drinking behaviour

29b. Ask family member to specify relative’s

enjoyable, healthy non-drinking behaviour (what)

30b. Ask family member to describe short term


enjoyable, healthy non-drinking behaviour

31b. Give family member examples of how Functional

Analysis of Non-drinking Behaviour information

will be used

252

Functional Analysis of Violent Behaviour

26c. Give family member reason for Functional



27c. Ask family member to describe a violent episode

28c. Ask family member to identify internal and

external triggers

29c. Ask family member to specify behaviour during

violent episode (what)

30c. Ask family member to describe short term


violent behaviour

31c. Give family member examples of how Functional

Analysis of Violent Behaviour information will be

used

Positive Communication Skills

32. Discuss reasons why communication skills are

important

33. Describe the 7 components of positive

communication

34. Give examples of good and inadequate

communication styles

35. Conduct a role play and provides feedback;

repeated

36. Conduct a reverse role play

37. Discuss positive communication skills at an

appropriate time

253

Use of Positive Reinforcement (Rewards)

38. Describe positive reinforcement and its role in

CRAFT

39. Describe the difference between enabling and

positive reinforcement

40. Discuss family member’s concerns about positive

reinforcement

41. Discuss and supports family member to identify

possible reinforcers available to use

42. Describe positive reinforcers as enjoyable,

inexpensive, available to give, easy to offer

43. Check that family member can recognise when

their relative has been drinking

44. Assist family member to identify their relative’s

healthy enjoyable non drinking behaviour to

reinforce

45. Demonstrate linking a reinforcer to healthy

behaviour using 7 steps of positive

communication

46. Check possible complications resulting from

reinforcer delivery

Time Out from Positive Reinforcement

47. Give family member reason for withdrawing

reinforcers, rewards

48. Ask family member to name reinforcers for

withdrawal using selection guidelines, e.g. safe,

easy, valued etc.

49. Ask family member to demonstrate use of

positive communication to explain the removal of

a reinforcer and linking it to their relative’s

behaviour

254

Allowing the Relative to Experience the Natural Consequences of Substance Use

50. Explore family member’s unconscious support for

their relative’s drinking

51. Give family member examples of unconscious

support

52. Give family member reasons for allowing natural

consequences

53. Assist family member to choose one situation to

use for allowing natural consequences

54. Ask family member family member to

demonstrate verbally linking natural

consequences with their relative’s behaviour

55. Discuss possible difficulties that may result from

family member allowing the natural

consequences

Helping Family Member Enrich Their Own Lives

56. Discuss with family member that all areas of their

life are important and reason for focus on family

member’s wellbeing

57. Assess family member’s feelings and thoughts

about different areas of their life that are

unrelated to their relative who drinks (Happiness

Scale)

58. Identify which areas of the family member’s life

needs attention (from Happiness Scale) that

family member want to concentrate on

59. Describe goals briefly and simply, in positive

words, with specific measurable behaviours, that

are reasonable and achievable

60. Describe goals that they can control, based on

their current or planned skills and knowledge

61. Describe goals that are independent of their

relative

62. Provide examples of new activities that can be

trialled

255

Inviting the Relative to Enter Treatment

63. Identify appropriate motivational hooks for their

relative

64. Role play inviting their relative using the selected

motivational hook and using positive

communication

65. Consider possible opportunities for extending the

invitation into treatment

66. Discuss possible treatment provider options

67. Participating in organizing ‘rapid intake’

68. Consider their relatives possible refusal or drop

out from treatment

69. Demonstrate the use of other methods of inviting

their relative into treatment e.g. phone call

during the session

General

70. Use problem solving

71. Give an assignment to do during the week

72. Review an assignment from previous session

Adapted from (Smith & Meyers 2004)

256

CRAFT Functional Analysis of a Relative’s (or Friend’s) Drinking Behaviour External Triggers Internal Triggers Behaviour Short-term positive consequences Long-term negative

consequences

Who is your

relative usually

with when

drinking?

Where does he/she

usually drink?

When does he/she

usually drink?

What do you think

your relative might be


before drinking?

What do you think

he/she might be

feeling right before

drinking?

What does your relative

usually drink?

How much does he/she

usually drink?

Over how long a period

of time does he/she

usually drink?

What do you think your relative likes about drinking

with … (whom)?

What do you think your relative likes about drinking at

… (where)?

What do you think your relative likes about drinking …

(when)?

What pleasant thoughts do you think he/she might

have while drinking?

What pleasant feelings do you think he/she might have

while drinking?

What do you think are the

negative results of your

relative’s drinking in each of

these areas (* the ones he/she

would agree with)?

Interpersonal

Physical

Emotional

Legal

Work/study

Financial

Other


257

CRAFT Functional Analysis of a Relative’s (or Friend’s) Non-drinking Behaviour External Triggers Internal Triggers Enjoyable, health

behaviour

Short term negative consequences Long term positive

consequences

Who is your relative

usually with when

…(behaviour)?

Where does he/she

usually…(behaviour)?

When does he/she

usually

…(behaviour)?

What do you think

your relative might

be thinking about

right before

…(behaviour)?

What do you think

your relative might

be feeling about right

before …(behaviour)?

What is your relative’s

enjoyable healthy

behaviour

How does he/she

engage in it?

How long a period does

it last?

What do you think your relative might dislikes about

...(behaviour) [with whom]?

What do you think he/she might dislike about

...(behaviour) [where]?

What do you think she might dislike about

...(behaviour) [when]?

What unpleasant thoughts do you think he/she might

have while ...(behaviour)?

What unpleasant feelings do you think he/she might

have while ...(behaviour)?


positive results of your

relative’s …(behaviour)? In

each of these areas?

Interpersonal

Physical

Emotional

Legal

Work/study

Financial

Other


258

CRAFT Functional Analysis of a Relative’s (or Friend’s) Violent Behaviour External Triggers Internal Triggers Violent Behaviour Short term positive

consequence

Long term negative

consequences

Who else is present besides

you when your relative gets

violent?

Where does the violence

usually occur?

When does the violence

usually occur?

What is the last thing you

say/do right before your

relative gets violent?

What do you think your

relative might be thinking

about right before getting

violent?


relative might be feeling about

right before getting violent?

Other ‘red flags’

What is the last thing your

relative says/does before

getting violent?

What does your relative’s

violent behaviour usually

consist of?


relative might like about

getting violent?

What pleasant thoughts do

you think your relative might

have during or right after the

violence?

What pleasant feelings do you

think your relative might have

during or right after the

violence?


negative results of your

relative’s violence in each of

these areas (* are the ones

she/he would agree with)?

Interpersonal

Physical

Emotional

Legal

Work/study

Financial

Other


259

Goals of Counselling Problem Areas/Goals Strategies Time Frame

1. In the area of drinking I would like:

2. In the area of job/educational progress I would like:

3. In the area of money management I would like:

4. In the area of social life I would like:

5. In the area of personal habits I would like:

6. In the area of intimate relationships I would like:

7. In the area of legal issues I would like:

8. In the area of emotional life I would like:

9. In the area of communication I would like:

10. In the area of happiness I would like:


260

Happiness Scale The scale is intended to estimate your current happiness with your life in each of the ten areas

listed below. Ask yourself the following question as you rate each area:

How happy am I with this area of my life?

Then circle one of the numbers (1-10) beside each area.

Numbers toward the left (lower numbers) indicate different levels of unhappiness, and

numbers toward the right (higher numbers) reflect different levels of happiness.

In other words, mark on the scale (1-10) exactly how you feel today. Also, try not to allow one

area to influence the results of the other areas.

Completely unhappy Completely happy

Drinking 1 2 3 4 5 6 7 8 9 10

job/education 1 2 3 4 5 6 7 8 9 10

Money 1 2 3 4 5 6 7 8 9 10

social life 1 2 3 4 5 6 7 8 9 10

personal habits 1 2 3 4 5 6 7 8 9 10

marriage/relations

hips

1 2 3 4 5 6 7 8 9 10

legal issues 1 2 3 4 5 6 7 8 9 10

emotional life 1 2 3 4 5 6 7 8 9 10

communication 1 2 3 4 5 6 7 8 9 10

general happiness 1 2 3 4 5 6 7 8 9 10


261

Relationship Happiness Scale The scale is intended to estimate your current happiness with your relationship in each of the

ten areas listed below. Ask yourself the following question as you rate each area:

How happy am I today with my partner in this area?

Then circle one of the numbers (1-10) beside each area.

Numbers toward the left (lower numbers) indicate different levels of unhappiness, and

numbers toward the right (higher numbers) reflect different levels of happiness.

In other words, mark on the scale (1-10) exactly how you feel today. Also, try not to allow one

area to influence the results of the other areas.

Completely unhappy Completely happy

household

responsibilities

1 2 3 4 5 6 7 8 9 10

raising the children 1 2 3 4 5 6 7 8 9 10

social activities 1 2 3 4 5 6 7 8 9 10

money management 1 2 3 4 5 6 7 8 9 10

Communication 1 2 3 4 5 6 7 8 9 10

sex & affection 1 2 3 4 5 6 7 8 9 10

job or school 1 2 3 4 5 6 7 8 9 10

emotional support 1 2 3 4 5 6 7 8 9 10

partner’s

independence

1 2 3 4 5 6 7 8 9 10

general happiness 1 2 3 4 5 6 7 8 9 10


262

Positive Communication

1. Be brief

2. Be positive

3. Refer to specific behaviours

4. Label your feelings

5. Offer an understanding statement

6. Accept partial responsibility

7. Offer to help


263

Problem Solving Problem solving steps Relative/friend response

Define the problem

narrowly

Brainstorm possible

solutions

Get rid of unwanted

suggestions

Select one possible

solution

Identify possible

obstacles/problems

Address each

obstacle/problem

Decide on the action

plan and do it

Review and evaluate

the outcome


264

Appendix F

Advertising poster for recruitment for the acceptability study

What do you think?

We are developing two programs to support Aboriginal and Torres Strait

Islander people who drink too much alcohol to cut down or stop drinking:

Individual Counselling & Family Training.

We want to know what Aboriginal and Torres Strait Islander community

members of Orange, Forbes, Condobolin and surrounding areas think about

the two programs.

[DATE]

[TIME]

[ADDRESS]

You will be given $40 for your time

For more information call [PARTICIPATING SERVICE DETAILS].

265

Appendix G

Acceptability survey information for particiapnts

Please note that the the names of the programs were changed from the Community

Reinforcement Approach (CRA) to the Personalised Alcohol Treatment (PAT) program, and from

Community Reinforcement and Family Training (CRAFT) to Family Training (FT), to avoid

confusion about the local community playing a role in each individually focused treatment

program. All other aspects of the CRA and CRAFT programs were maintained.

Drinking too much alcohol causes physical and mental health problems as well as social

problems, not just for people who drink, but also for their families and community.

Health workers can help people who need to cut down or stop drinking alcohol to

improve their physical and mental wellbeing. Health workers can also help families and

communities by teaching them how to better support family members and friends,

who need to cut down or stop drinking alcohol.

What we would like to do

We would like to deliver two programs to see if they work to help Aboriginal (including

Torres Strait Islander) people who need to cut down or stop drinking alcohol.

Personalised Alcohol Treatment

(PAT) program for Aboriginal people

who need to cut down or stop

drinking alcohol.

Family Training (FT) program for

family members/friends of Aboriginal

people who need to cut down or stop

drinking alcohol.

Who will be delivering these programs?

The programs will be delivered through Yoorana Gunya Family Violence Healing Centre

Aboriginal Corporation and the Lyndon Community to Aboriginal people in Forbes,

Orange and surrounding areas.

Program One Program Two

266

Who else will be involved?

The National Drug and Alcohol Research Centre at the University of New South Wales

will work closely with the services delivering the programs to see if they work to help

Aboriginal people who need to cut down or stop drinking alcohol.

Why are we inviting you to answer these questions?

You are being invited to answer the questions in this survey because you are a new or

existing client of Yoorana Gunya Family Violence Healing Centre Aboriginal Corporation

or the Lyndon Community.

What we would like to know from you

Before we start delivering the two programs, we would like to find out what Aboriginal

clients of Yoorana Gunya and the Lyndon Community think of each one. We are also

interested in any suggestions you have to improve each program (there is a section in

the survey where you can write down your suggestions).

How confidential are you answers?

All your answers are confidential. Researchers from the University of New South Wales

and the Lyndon Community will be able to look at your answers. The answers to the

survey will be stored on a computer file at the University of New South Wales. If you

provide us with your name and address, these details will not be linked to your survey

answers.

If you are not sure about any of these questions, or would like more information about

the study, please call Anton Clifford on (02) 9385 0386 at the Faculty of Medicine,

University of New South Wales.

If you have any concerns as a result of completing this survey please contact the

closest health service:

Lyndon Community Julaine Allan (02) 6361 1521

Yoorana Gunya Donna Bliss (02) 6851 5111

If you have any complaints you should contact the AHMRC Ethics Committee and the

UNSW Ethics Committee as follows:

The Chairperson, AHMRC Ethics

Committee

PO Box 1565, Strawberry Hills NSW 2012

Ph (02) 9212 4777, Fax (02) 9212 7211

Email [email protected]

UNSW Ethics Secretariat, The University of

New South Wales, SYDNEY 2052

AUSTRALIA

Ph (02) 9385 4234, Fax (02) 9385 6648

Email [email protected]



267

How to answer the questions

The questions require you to choose an answer that best describes what you think.

Please ask a group leader if you do not understand a question. Please be as honest and

accurate as you can be. Remember all your answers are confidential and we will not

give your name and address to anyone who is not a health practitioner in this service.

Be aware that you may withdraw your participation at any time without needing a

reason.

THANK YOU.

268

Appendix H

Intervention information and acceptability survey

Please note that the the names of the programs were changed from the Community

Reinforcement Approach (CRA) to the Personalised Alcohol Treatment (PAT) program, and from

Community Reinforcement and Family Training (CRAFT) to Family Training (FT), to avoid

confusion about the local community playing a role in each individually focused treatment

program. All other aspects of the CRA and CRAFT programs were maintained.

Personalised Alcohol Treatment (PAT)

Who is PAT for?

o Aboriginal and Torres Strait Islander people from Orange, Forbes

and surrounding areas who need help to cut down or stop

drinking alcohol.

What is PAT?

o One-on-one counselling with a drug and alcohol counsellor who

has been trained to deliver the program.

o To reduce alcohol-related harms experienced by the drinker,

their family and their community.

o Assessment of risk of harms from alcohol.

o Personalised treatment plan.

o Support to cut down or stop drinking alcohol.

When can PAT be delivered?

o After withdrawal.

o If needing rehab but not wanting to go.

o Waiting for rehab.

o After rehab.

269

PART A: Personalised Alcohol Treatment (PAT)

Please circle ONE number for question 1.

1. What do you think about PAT being delivered in your community?

1 2 3 4 5

very bad very good

Please tick () ONE box for each part of question 2.

2. Do you think it is okay for PAT to be available for Aboriginal people:

2a. After withdrawal?

not okay

okay

2b. Needing rehab but not wanting to go?

not okay

okay

2c. Waiting for rehab?

not okay

okay

2d. After rehab?

not okay

okay

2e. Referred from probation and parole?

not okay

okay

ID:

270

Imagine you drink too much alcohol and want help to cut down or stop.

Please tick () ONE box for each part of questions 3 to 8.

3. What are the qualities that you think are most important in a counsellor:

3a. Trust and familiarity?

someone I know and trust

someone I know

someone I trust

doesn’t matter

3b. Experience working in your local community?

no

yes

doesn’t matter

3c. Aboriginality?

a non-Aboriginal person

an Aboriginal person

doesn’t matter

3d. Gender?

a woman

a man

doesn’t matter

4. Would you feel okay to talk one-on-one with a counsellor, who has the qualities

you have described above, about:

4a. How much alcohol you usually drink?

okay

not okay

4b. How you feel about your drinking?

okay

not okay

4c. What you do when you are drinking?

okay

not okay

271

4d. If you cause harm to yourself and/or others when you drink (including any

violent behaviour)?

okay

not okay

4e. Setting goals to cut down or stop drinking?

okay

not okay

4f. Things (people, places, and situations) that might be making you want to

drink?

okay

not okay

4g. Ways to resolve problems that might be making you want to drink?

okay

not okay

4h. How to use support from a trusted family member/friend to cut down or stop

drinking?

okay

not okay

5. Would it be okay for one or more of your most trusted family members/friends

to:

5a. Help you to start alcohol treatment?

not okay

okay

5b. Help you to stay in alcohol treatment?

not okay

okay

5c. Help you to continue to drink less or stop drinking?

not okay

okay

272

6. Would it be okay for one or more of your concerned family members/friends to:


okay

not okay

6b. Help you to stay in alcohol treatment?

okay

not okay


okay

not okay

7. If you were attending PAT to get help to cut down or stop drinking, what would

you prefer as part of the one-on-one sessions:

7a. Number of sessions?

1 to 2 sessions for very basic information

2 to 3 sessions for basic information

3 to 4 sessions for detailed information

5 or more sessions for very detailed information

8. If group sessions were made available on top of one-on-one counselling, would it

be okay (in a group setting) for you to:

8a. Confidentially talk to Aboriginal people with similar experiences about

alcohol and its effects on yourself and/or your family?

not okay

okay

8b. Practice and reinforce skills learnt in one-on-one counselling?

not okay

okay

8c. Participate in healthy social and recreational activities?

not okay

okay

273

Imagine you are having a one-on-one counselling session as part of the Personalised

Alcohol Treatment (PAT) program.

Please write numbers 1, 2, 3, and 4 in the boxes below to show how important you

think each part of the session is (use each number once).

9. Please rank the session parts below from 1 (most important) to 4 (least

important).

Talking about your

drinking behaviours

Setting goals to

reduce alcohol-

related harms

Learning how to

resolve alcohol-

related problems

Practising how to

resolve alcohol-

related problems.

274

Please write your suggestions for the PAT program in the box below.

10. Is there anything we haven’t asked you about that you think we should include in

the Personalised Alcohol Treatment (PAT) program?

END OF PART A

275

Family Training (FT)

Who is FT for?

o Aboriginal and Torres Strait Islander people from Orange,

Forbes and surrounding areas who have a family

member/friend who drinks too much alcohol.

What is FT?

o One-on-one counselling with a drug and alcohol worker who

has been trained to deliver the program.

o To talk about affects of family member’s/friend’s drinking.

o Training and support for people who want to help a family

member/friend who needs to cut down or stop drinking

alcohol.

o To increase the wellbeing of people with a family

member/friend who drinks too much alcohol.

When can FT be delivered?

o For people who have a family member/friend in the

withdrawal unit.

o For people who want to help a family member/friend to start

alcohol treatment.

o For people who have a family member/friend who is waiting

for rehab.

o For people who have a family member/friend who has

finished rehab.

276

PART B: Family Training (FT)


1. What do you think about FT being delivered in your community?

1 2 3 4 5

very bad very good

Please tick () ONE box for each part of question 2.

2. Do you think it is okay for FT to be available for Aboriginal people:

2a. With a family member/friend in the withdrawal unit?

okay

not okay

2b. Who want to help a family member/friend who drinks too much alcohol to

start treatment?

okay

not okay

2c. With a family member/friend who is waiting for rehab?

okay

not okay

2d. With a family member/friend who has just finished rehab?

okay

not okay

2e. With a family member/friend who has been referred from probation and

parole?

okay

not okay

ID:

277

Imagine you want to help a family member/friend who drinks too much alcohol.

3. Would you be comfortable asking your family member/friend who drinks too

much alcohol:

3a. How much alcohol he/she drinks?

not comfortable

comfortable

3b. How he/she feels about his/her own drinking?

not comfortable

comfortable

3c. What he/she does when drinking alcohol?

not comfortable

comfortable

Please tick () ONE box for each part of questions 3 to 7.

4. What are the qualities you think are most important in a drug and alcohol

worker:

4a. Trust and familiarity?


someone I know

someone I trust

doesn’t matter

4b. Experience working in your local community?

yes

no

doesn’t matter

4c. Aboriginality?



doesn’t matter

4d. Gender?

a man

a woman

doesn’t matter

278

5. Would you feel okay to talk one-on-one with a drug and alcohol worker, who has

the qualities you have described, about:

5a. How much alcohol your family member/friend drinks?

okay

not okay

5b. What your family member/friend does when he/she drinks alcohol?

okay

not okay

5c. If your family member/friend harms themselves or others when he/she drinks

alcohol (including any violent behaviour)?

okay

not okay

6. Would you feel okay about using FT to work on:

6a. How to talk to your family member/friend about his/her drinking?

not okay

okay

6b. Ways to talk to your family member/friend about how alcohol is causing

difficulty in your community?

not okay

okay

6c. Ways you can support your family member/friend to start treatment?

not okay

okay

6d. Ways you can support your family member/friend to stay in treatment?

not okay

okay

6e. Ways to support your family member/friend to continue to drink less?

not okay

okay

6f. Ways to set boundaries when alcohol causes difficulty in your community?

not okay

okay

279

6g. Ways you can stay strong living in a community where alcohol causes

difficulty?

not okay

okay

6h. Ways to you can help your community stay strong when alcohol causes

difficulty?

not okay

okay

7. If you were attending FT so that you could help a family member/friend who

drinks too much alcohol, what would you prefer as part of the one-on-one

sessions:






8. If group sessions were made available on top of one-on-one counselling, would it

be okay (in a group setting) for you to:

8a. Confidentially talk to Aboriginal people with similar experiences about

alcohol and its effects on yourself and/or your family?

okay

not okay

8b. Practise and reinforce skills learnt in one-on-one counselling?

okay

not okay


okay

not okay

280

Imagine you are having one-on-one sessions as part FT.

Please write numbers 1, 2, 3, & 4 in the boxes below to show how important you

think each part of the session is (use each number once).

9. Please rank the session parts below from 1 (most important) to 4 (least

important).

Talking about your family

member’s/friend’s drinking behaviour

Learning how to communicate with

your family member/friend about his/her

drinking

Learning how to support your family member/friend to cut down or stop

drinking

Practicing how to support your family member/friend to cut down or stop

drinking

281

Please WRITE your suggestions for the FT program in the box.

10. Is there anything we haven’t asked you about that you think we should include in

the Family Training (FT) program?

END OF PART B

282

PART C: Information about you

The questions in this section provide us with some information about you. Remember that this information is confidential and so will only be used for the research project and will not forwarded on to any authorities or other organisations.

Please tick () ONE box for each part of questions 1 to 12 and WRITE answers where shown.

1. Health service attended

Lyndon Community

Yoorana Gunya

other (please write)

2. Gender

female

male

3. Date of birth

(day) (month) (year) (please write)

4. Did you guess any part of your birth date?

no

yes, I estimated (please write)

ID:

283

5. Are you of Aboriginal or Torres Strait Islander origin?

no (if no, go to question 7)

yes, Aboriginal

yes, Torres Strait Islander

yes, Aboriginal and Torres Strait Islander

6. What clan, tribal or language group do you identify with?

I identify with (please write)

7. Do you have a spouse (husband/wife) or child who is of Aboriginal or Torres Strait Islander origin?

no

yes, spouse and child

yes, spouse only

yes, child only

8. Were you born in Australia?

yes

no, I was born in (please write)

9. What language do you prefer to speak at home?

English

other, I prefer to speak (please write)

10. Have you completed any formal education?

no formal education

284

primary school (year 6)

high school (year 10)

school certificate (year 12)

tertiary education (university or TAFE)

I do not want to answer

11. Do you work?

don’t work (if you don’t work, go to question 13)

full-time work

part-time work

casual work


12. What do you do for work?

(please write)


13. How many other people (not including yourself) live where you usually do?

(please write)

285


14. Does the place you usually live meet your needs?

1 2 3 4 5

does not meet my

needs at all

meets all my needs

Please tick () ONE option for question 14.

39. 15. Do you have a family member/friend who needs to cut down or stop drinking

alcohol?

no (If no, you have completed Part C)

yes


40. 16. How worried are you are about your family member/friend who needs to cut

down or stop drinking alcohol?

41.

1 2 3 4 5

not worried

at all

very worried

END OF PART C

286

PART D: Substance use These questions ask about your alcohol and other drug use. Remember you can

withdraw your participation at any time, so you don’t have to answer these questions

if you don’t want to.

Please tick () ONE box next to the answer that is right for you for each part of

questions 1 to 10.

1. How often do you drink?

never

monthly or less

2-4 times a month

2-3 times a week


2. When you have a drink, how many do you usually have in one day?

1 or 2

3 or 4

5 or 6

7-9

10 or more

3. How often do you have six or more drinks on one day?

never

less than monthly

monthly

weekly

daily or almost daily

4. In the last year, how often have you found you weren’t able to stop drinking once

you started?

never

less than monthly

monthly

weekly


5. In the last year, how often has drinking got in the way of doing what you need to

do?

never

less than monthly

monthly

weekly


6. In the last year, how often have you needed a drink in the morning to get yourself

going?

never

less than monthly

monthly

weekly


ID:

287

7. In the last year, how often have you felt bad about your drinking?

never

less than monthly

monthly

weekly


8. In the last year, how often have you had a memory lapse or blackout because of

your drinking?

never

less than monthly

monthly

weekly


9. Have you injured yourself or anyone else because of your drinking?

No

yes, but not in the past year


10. Has anyone (family, friend, doctor) been worried about your drinking or asked

you to cut down?

No

yes, but not in the past year

yes, during the past year

11. Are you an ex-drinker?

no

yes

Please WRITE ANWERS where shown for question 12.

12. How many days in the last month (30 days) did you use the following drugs:

12a. Tobacco days

12b. Cannabis days (yarndi, marijuana, pot, weed)

12c. Amphetamines days (speed, ecstacy uppers, goey, crystal meth, ice)

12d. Cocaine days

12e. Heroin days

12f. Illegally obtained opioid drug days (morphine, pethidine,

codeine, not heroin)

12g. Over the counter medication days (NoDoz, pain killers, anti-

inflammatory)

288

12h. Tranquilisers days (benzos, valium, rohypnol)

12i. Other drug not listed above days

Please specify which drug

END OF PART D

Thank you for completing the survey!

289

Appendix I

Slides used to present the acceptability survey in a standardised manner

What do you think?

Programs to help Aboriginal and Torres Strait Islander people who drink too much alcohol and their family members/friends

1

2

Information sheets are handed out

by the group leader

290

Overview

3

Drinking too much alcohol causes:

Health problems (physical & mental)

Social problems

Problems are experienced by the people who drink as

well as their families & community

Health workers can help

Teaching families & communities how to better support people

who need to cut down or stop drinking

What we would like to do

4

Program 1 Program 2

Personalised Alcohol Treatment

(PAT) program

For Aboriginal and Torres Strait Islander

people who need to cut down or stop

drinking alcohol

Family Training

(FT) program

For family members/friends of Aboriginal

and Torres Strait Islander people who

need to cut down or stop drinking alcohol

291

Who will be delivering these programs?

5

Yoorana Gunya Family Violence Healing Centre Aboriginal Corporation

Who else will be involved?

6

292

Why are we inviting you to answer these

questions?

7

New or existing clients of to health services:

Lyndon Community

Yoorana Guyna

What we would like to know from you

8

What you think of the two programs

Personalised Alcohol Treatment (PAT) program

Family Training (FT) program

Suggestions you have to improve the programs

293

How confidential are your answers?

9

All answers are confidential.

Researchers from UNSW and the Lyndon Community

will have access to your survey answers.

If you provide us with your name and address, these

details will not be linked to your survey answers.

Questions & Concerns

10

Questions

Anton Clifford, UNSW, (02) 93850386

Concerns

Julaine Allan, Lyndon Community, (02) 63611521

Donna Bliss, Yoorana Guyna, (02) 68515111

294

Complaints

11

The Chairperson

AHMRC Ethics Committee

PO Box 1565, Strawberry Hills NSW 2012

Ph: (02) 9212 4777, Fax: (02) 9212 7211


UNSW Ethics Secretariat

UNSW, SYDNEY 2052 AUSTRALIA

Ph: (02) 9385 4234, Fax: (02) 9385 6648


How to answer the questions?

12

Follow instructions carefully. We cannot use your answers if you do not follow the instructions.

Choose an answer that best describes what you think.

Ask if you do not understand.

Be honest & accurate.

You may withdraw your participation at any time without needing a reason.



295

13

Any questions?

Your ID code

14

Survey will be given out in parts.

Your ID code will only be used to link different parts of your

survey together.

296

Create your ID code

15

Create your ID code (e.g. 16DIA)

The date you were born (e.g. 16)

AND

First three letters of your mother’s name (e.g. DIA)

Please write your ID CODE on the top of your information sheet

16

PAT information sheets are handed out

by the group leader

297

Personalised Alcohol Treatment (PAT)

17

Who is PAT for? Aboriginal and Torres Strait Islander people from Orange, Forbes and

surrounding areas who need help to cut down or stop drinking alcohol.

What is PAT?

One-on-one counselling with a drug and alcohol counsellor who has been trained to deliver the program.

To reduce alcohol-related harms experienced by the drinker, their family and their community.

Assessment of risk of harms from alcohol.

Personalised treatment plan.

Support to cut down or stop drinking alcohol.

When can PAT be delivered? After withdrawal.

If needing rehab but not wanting to go.

Waiting for rehab.

After rehab.

Part A: PAT program

18

Part A is handed out by the group leader

Please write your ID CODE at the top of Part A

298

Part A: PAT program

19

1. What do you think about PAT being delivered in your

community? [page 1]

Please circle one number

1 2 3 4 5

very bad very good

Part A: PAT program

20

2. Do you think it is okay for PAT to be available for Aboriginal

people: [page 1]

2a. After withdrawal?

not okay

okay

Please tick () one box

299

Part A: PAT program

21


people: [page 1]

2b. Needing rehab but not wanting to go?

not okay

okay


Part A: PAT program

22


people: [page 1]

2c. Waiting for rehab?

not okay

okay


300

Part A: PAT program

23


people: [page 1]

2d. After rehab?

not okay

okay


Part A: PAT program

24


people: [page 1]

2e. Referred from probation and parole?

not okay

okay


301

25

Imagine you drink too much alcohol

and want help to cut down or stop

Part A

26

3. What are the qualities that you think are most important in a

counsellor? [page 2]

3a. Trust & familiarity:


someone I know

someone I trust

doesn’t matter




302

Part A

27



3b. Experience working in your local community:

no

yes

doesn’t matter




Part A

28



3c. Aboriginality:

a non-aboriginal person


doesn’t matter




303

Part A

29



3d. Gender:

a woman

a man

doesn’t matter




Part A

30

4. Would you feel okay to talk one-on-one with a counsellor, who

has the qualities you have described above, about: [page 2]

4a. How much alcohol you usually drink?

okay

not okay




304

Part A

31



4b. How you feel about your drinking?

okay

not okay




Part A

32



4c. What you do when you are drinking?

okay

not okay




305

Part A

33



4d. If you cause harm to yourself and/or others when you drink

(including any violent behaviour)?

okay

not okay




Part A

34



4e. Setting goals to cut down or stop drinking?

okay

not okay




306

Part A

35



4f. Things (people, places, and situations) that might be making you

want to drink?

okay

not okay




Part A

36



4g. Ways to resolve problems that might be making you want to

drink?

okay

not okay




307

Part A

37



4h. How to use support from a trusted family member/friend to cut

down or stop drinking?

okay

not okay




Part A

38

5. Would it be okay for one of your most trusted family

members/friends to: [page 3]


not okay

okay




308

Part A

39



5b. Help you to stay in treatment?

not okay

okay




Part A

40




not okay

okay




309

Part A

41

6. Would it be okay for one of your concerned family



okay

not okay




Part A

42



6b. Help you to stay in treatment?

okay

not okay




310

Part A

43




okay

not okay




Part A

44

7. If you were attending PAT to get help to cut down or stop

drinking, what would you prefer as part of the one-on-one

sessions? [page 7]









311

Part A

45

8. If group session were made available on top of one-on-one

counselling, would it be okay (in a group setting) for you to: [page 4]

8a. Confidentially talk to Aboriginal people with similar experiences

about alcohol and its effects on yourself and/or your family?

not okay

okay




Part A

46

8. If group session were made available on top of one-on-one counselling, would it be okay (in a group setting) for you to: [page 4]


not okay

okay




312

Part A

47



not okay

okay




Part A

48

Remember you can withdraw your

participation at any time without

needing a reason

313

49

Imagine you are having a

one-on-one counselling session as

part of PAT

Part A

50

9. Please rank the session parts below from 1 (most important)

to 4 (least important) [page 5]

Please write numbers 1, 2, 3 or 4 in the boxes (use each number once)

Imagine you are having a one-on-one

counselling session as part of

PAT

Talking about your

drinking behaviours

Setting goals to

reduce alcohol-

related harms

Learning how to

resolve alcohol-

related problems

Practicing how to

resolve alcohol-

related problems

314

Part A

51

10. Is there anything we haven’t asked you about that you think we should include in the Personalised Alcohol Treatment (PAT) program? [page 6]

Please write your suggestions in the box

I think that

Part A

52

END OF PART A

The group leader will collect Part A

when you have finished

315

53

FT information sheets are handed out

by the group leader

Family Training (FT)

54

Who is FT for?

Aboriginal and Torres Strait Islander people from Orange, Forbes and surrounding areas who have a family member/friend who drinks too much alcohol.

What is FT?

One-on-one counselling with a drug and alcohol worker who has been trained tpdeliver the program.

To talk about affects of family member’s/friend’s drinking.

Training and support for people who want to help a family member/friend who needs to cut down or stop drinking alcohol.

To increase the wellbeing of people with a family member/friend who drinks too much alcohol.

When can FT be delivered?

For people who have a family member/friend in the withdrawal unit.

For people who want to help a family member/friend to start alcohol treatment.

For people who have a family member/friend who is waiting for rehab.

For people who have a family member/friend who has finished rehab.

316

Part B: FT program

55

Part B is handed out by the group leader

Please write your ID CODE at the top of Part B

Part B: FT program

56

1. What do you think about FT being delivered in your

community? [page 1]


1 2 3 4 5

very bad very good

317

Part B: FT program

57

2. Do you think it is okay for FT to be available for Aboriginal

people: [page 1]

2a. With a family member/friend in the withdrawal unit?

okay

not okay


Part B: FT program

58


people: [page 1]

2b. Who want to help a family member/friend who drinks too much

alcohol to start treatment?

okay

not okay


318

Part B: FT program

59


people: [page 1]

2c. With a family member/friend who is waiting for rehab?

okay

not okay


Part B: FT program

60


people: [page 1]

2d. With a family member/friend who has just finished rehab?

okay

not okay


319

Part B: FT program

61

2. Do you think it is okay for FT to be available for Aboriginal people: [page 1]

2e. With a family member/friend who has been referred from probation and parole?

okay

not okay


62

Imagine you want to help

a family member/friend

who drinks too much alcohol

320

Part B

63

3. Would you be comfortable asking your family member/friend

who drinks too much alcohol: [page 2]

3a. How much alcohol he/she drinks?

not comfortable

comfortable


Imagine you want to help a family

member/friend who drinks too much

alcohol

Part B

64



3b. How he/she feels about his/her own drinking?

not comfortable

comfortable




alcohol

321

Part B

65



3c. What he/she does when drinking alcohol?

not comfortable

comfortable




alcohol

Part B

66

4. What are the qualities that you think are most important in a drug and alcohol worker: [page 2]

4a. Trust & familiarity?


someone I know

someone I trust

doesn’t matter




alcohol

322

Part B

67


drug and alcohol worker? [page 2]

4b. Experience working in your local community:

yes

no

doesn’t matter




alcohol

Part B

68



4c. Aboriginality:



doesn’t matter




alcohol

323

Part B

69



4d. Gender:

a man

a woman

doesn’t matter




alcohol

Part B

70

5. Would you feel okay to talk one-on-one with a drug and

alcohol worker, who has the qualities you have described

above, about: [page 3]

5a. How much alcohol your family member/friend drinks?

okay

not okay




alcohol

324

Part B

71




5b. What your family member/friend does when he/she drinks

alcohol?

okay

not okay




alcohol

Part B

72




5c. If your family member/friend harm themselves or others when

he/she drinks alcohol (including any violent behaviour)?

okay

not okay




alcohol

325

Part B

73

6. Would you feel okay about using FT to work on: [page 3]

6a. How to talk to your family member/friend about his/her drinking?

not okay

okay




alcohol

Part B

74


6b. Ways to talk to your family member/friend about how alcohol is

causing difficulty in your community?

not okay

okay




alcohol

326

Part B

75


6c. Ways you can support your family member/friend to start

treatment?

not okay

okay




alcohol

Part B

76


6d. Ways you can support your family member/friend to stay in

treatment?

not okay

okay




alcohol

327

Part B

77


6e. Ways to support your family member/friend to continue to drink?

not okay

okay




alcohol

Part B

78


6f. Ways to set boundaries when alcohol causes difficulty in your

community?

not okay

okay




alcohol

328

Part B

79


6g. Ways you can stay strong living in a community where alcohol

causes difficulty?

not okay

okay




alcohol

Part B

80


6h. Ways to you can help your community stay strong when alcohol

causes difficulty?

not okay

okay




alcohol

329

Part B

81

7. If you were attending FT so that you could help a family member/friend who drinks too much alcohol, what would you prefer as part of the one-on-one sessions: [page 4]









alcohol

Part B

82

8. If group session were made available on top of one-on-one

counselling, would it be okay (in a group setting) for you to: [page 4]

8a. Confidentially talk to Aboriginal people with similar experiences

about alcohol and its effects on yourself and/or your family?

okay

not okay




alcohol

330

Part B

83



okay

not okay




alcohol

Part B

84



okay

not okay




alcohol

331

85

Imagine you are having a

one-on-one counselling session as

part of FT

Part B

86

9. Please rank the session parts below from 1 (most important) to 4 (least important) [page 5]

Please write numbers 1, 2, 3, & 4 in the boxes (use each number once)

Imagine you are having one-on-one

sessions as part of

FT

Talking about your

family

member’s/friend’s

drinking behaviour

Learning how to

communicate with

your family

member/friend

about his/her

drinking

Learning how to

support your family

member/friend to

cut down or stop

drinking

Practicing how to

support your family

member/friend to

cut down or stop

drinking

332

Part B: FT program

87

10. Is there anything we haven’t asked you about that you think we should include in the Family Training (FT) program? [page 6]

Please write your suggestions in the box

The FT program would be better if

Part B: FT program

88

END OF PART B

The group leader will collect Part B


333

Part C: Information about you

89

Part C is handed out by the group leader

Please write your ID CODE at the top of Part C


90

Remember that this information will be

used for the research project and not

forwarded on to any authorities

334


91

1. Health service attended [page 1]

Lyndon Community

Yoorana Gunya

other (please write)

Please tick () one box and write answer where shown


92

2. Gender [page 1]

female

male



335


93

3. Date of birth [page 1]

(day) (month) (year)

Please write answer where shown


94

4. Did you guess any part of your birth date? [page 1]

no

yes, I estimated (please write)


336


95

5. Are you of Aboriginal or Torres Strait Islander origin? [page 2]

no (if no, go to question 22)

yes, Aboriginal

yes, Torres Strait Islander

yes, Aboriginal and Torres Strait Islander



96

6. What clan, tribal or language group do you identify with? [page 2]

I identify with (please write)


337


97

7. Were you born in Australia? [page 2]

yes

no, I was born in (please write)



98

8. What language do you prefer to speak at home? [page 2]

English

other, I prefer to speak (please write)


338


99

9. Have you completed any formal education? [page 2]

no formal education

primary school (year 6)

high school (year 10)

school certification (year 12)

tertiary education (university or TAFE)




100

10. Do you work? [page 3]

don’t work (if you don’t work, go to question 12)

full-time work

part-time work

casual work

other



339


101

11. What do you do for work? [page 3]

(please write)


Please tick () one box or write answer where shown


102

12. How many other people (not including yourself) live where you usually do? [page 3]

(please write)


340


103

13. Does the place where you usually live meet your

needs? [page 3]


1 2 3 4 5

does not

meet my

needs at all

meets all my

needs


104

14. Do you have a family member who needs to cut down or stop drinking? [page 4]

no (if no, you have completed Part C)

yes


341


105

15. How worried are you about your family member/friend

who needs to cut down or stop drinking alcohol? [page 4]


1 2 3 4 5

not worried

at all

very worried


106

END OF PART C

The group leader will collect Part C


342

107

Expression of interest sheet is handed out

by the group leader

Interested in being involved?

108

If you are interested in being involved in the PAT or FT programs

please fill in your contact details.

These details will be used by Yoorana Gunya and Lyndon

Community staff to contact you about your participation in the

program/s.

Providing your contact details is voluntary.

Your contact details will not be linked to your survey answers.

343

Interested in being involved?

109

Name: (please write)

Address: (please write)

Home phone: (please write)

Mobile phone: (please write)

I am a person who needs to cut down or stop drinking alcohol

AND/OR

I have a family member/friend who needs to cut down or stop

drinking alcohol

Please tick () one or both boxes that apply to you

110

The group leader will collect

your expression of interest sheet

when you are finished

344

Part D: Alcohol use

111

Part D

• Questions in Part D ask about your drinking.

• Examples of questions that could be used in the programs.

• Remember you can withdraw your participation at any time, so you do not have to answer these questions

• if you do not want to.

• You will be able to get feedback on your answers if you complete Part D.

Part D: Alcohol use

112

Part D is handed out by the group leader

Please write your ID CODE at the top of Part D

345

Part D: Alcohol use

113

1. How often do you drink? [page 1]

never

monthly or less

2-4 times a month

2-3 times a week



Part D: Alcohol use

114

2. When you drink, how many do you usually have in one day? [page 1]

1 or 2

3 or 4

5 or 6

7-9

10 or more


346

Part D: Alcohol use

115

3. How often do you have six or more drinks on one day? [page 1]

never

less than monthly

monthly

weekly



Part D: Alcohol use

116

4. In the last year, how often have you found you weren’t able to stop drinking once you started? [page 1]

never

less than monthly

monthly

weekly



347

Part D: Alcohol use

117

5. In the last year, how often has drinking got in the way of doing what you need to do? [page 1]

never

less than monthly

monthly

weekly



Part D: Alcohol use

118

6. In the last year, how often have you needed a drink in the morning to get yourself going? [page 2]

never

less than monthly

monthly

weekly



348

Part D: Alcohol use

119

7. In the last year how often have you felt bad about your drinking? [page 2]

never

less than monthly

monthly

weekly



Part D: Alcohol use

120

8. In the last year, how often have you has a memory lapse or blackout because of your drinking? [page 2]

never

less than monthly

monthly

weekly



349

Part D: Alcohol use

121

9. Have you injured yourself or anyone else because of

your drinking? [page 2]

no

yes, but not in the last year

yes, during the last year


Part D: Alcohol use

122

10. Has anyone (family, friend, doctor) been worried about

your drinking or asked you to cut down? [page 2]

no

yes, but not in the last year

yes, during the last year


350

Part D: Alcohol Use

123

END OF PART D

351

Appendix J

Group record sheet for acceptability survey

Acceptability study: group record sheet

Please fill in this form for each group that is involved in the acceptability study.

Date:

Service:

Start time:

End time:

Group leaders name:

Number of clients invited to

participate:

Number of clients consented to

participate:

Number of clients completed the

survey:

Comments:

352

Appendix K

Additional methods and results not included in the published paper (Calabria et al.

2013)

Additional acceptability survey content

In addition to asking about the overall acceptability of the program, parts A and B of the survey

asked whether particular content and delivery options were acceptable. The Community

Reinforcement Approach (CRA) program survey (part A) asked about the acceptability of

program setting and delivery, counsellor characteristics, session discussion topics, and family

member’s involvement in treatment. The Community Reinforcement and Family Training

(CRAFT) program survey (part B) asked about the acceptability of setting and delivery,

communication with the drinker, counsellor characteristics, and session discussion topics.

Participants were also asked to rank in order of importance four session components. The CRA

program components to be ranked were: talking about your drinking behaviour, setting goals

to reduce alcohol-related harms, learning how to resolve alcohol-related problems, and

practicing how to resolve alcohol-related problems. The CRAFT program components to be

ranked were: talking about your family member’s/friend’s drinking behaviour, learning how to

communicate with your family member/friend about his/her drinking, learning how to support

your family member/friend to cut down or stop drinking, and practicing how to support your

family member/friend to cut down or stop drinking.

In addition to demographic information (part C) presented in the published paper participants

were asked which health service he/she attended, clan/tribal/language group, country of birth,

preferred language, how many people usually lived with, whether residence meets needs

(rated on a five-point scale, 1=does not meet my needs at all, 5=meets all my needs).

353

Alcohol use (part D) was measured using the Alcohol Use Disorders Identification Test (AUDIT)

(Saunders et al. 1993; Saunders & Aasland 1987). The AUDIT measures hazardous and harmful

alcohol consumption in the past 12 months and covers the domains of alcohol consumption,

drinking behaviour, and alcohol-related problems. The AUDIT is a ten item scale: items one to

eight are scored on a 5-point Likert scale and items nine and ten are scored on a 3-point Likert

scale. Total scores range from zero to forty and a high score indicates problematic alcohol

misuse. Universally used cut-off scores determine participants’ drinking behaviour: non-

drinker (score of 0); drinks within recommended limits (score of 1-7); at-risk drinking (score of

8-12); or high-risk drinking (score of 13 or more) (Conigrave, Hall & Saunders 1995; Tsai et al.

2005; Babor et al. 2001). Although the measure has not been validated for Aboriginal

Australians, it has been designed as a cross-cultural instrument (Saunders et al. 1993) and is

recommended by the Alcohol Treatment Guidelines for Indigenous Australians (Australian

Government Department of Health and Ageing 2007). The AUDIT has high internal consistency

across diverse samples and settings (median alpha = 0.83) and the English language version has

demonstrated validity (Reinert & Allen 2007). The wording used for the AUDIT in the current

study was taken from an Aboriginal-specific adaptation developed by researchers at the

University of Sydney and Sydney South West Area Health Service: the content is the same but

phasing slightly altered to be more appropriate for Aboriginal Australians. For example, instead

of “how many standard drinks do you have on a typical day?” the Aboriginal-specific version

asks “when you drink, how many do you usually have?”. Participants were also asked if they

had a family member/friend who needed to cut down or stop drinking and how worried they

were about that family member/friend (rated on a 5-point Likert scale, 1=not worried at all,

5=very worried). Tobacco and illicit drug consumption was measured using frequency

questions. Formal and slang names of drugs were listed to maximise comprehension.

354

Additional procedure information

Participants were lead through the survey process and sections of the survey were handed out

separately. The process was guided by a researcher or Aboriginal Health Worker who followed

steps outlined in a PowerPoint presentation designed to standardise the process of survey

delivery (see Appendix I for PowerPoint slides). First, the study aims were explained and an

information sheet was given to participants including information on consent. Consenting

participants were asked to generate an identification number for themselves, which they

wrote on the information sheet for future reference, and were then asked to write on each

section of their survey, later used to link their sections of the survey. The identification number

consisted of the date the participant was born and the first three letters of their mother’s

name (e.g. 16DIA). Second, general information was presented on the CRA program, including

who the program was for, what the program involved (e.g. individual one-on-one counselling

with a trained counsellor to reduce alcohol-related harms experienced by the drinker, their

family and their community), and when the program could be delivered. After program

information was presented participants were given part A of the survey and asked to imagine

that they had a drinking problem and needed help to cut down or stop, before recording their

opinions on the content of the CRA program. Third, general information was presented on the

CRAFT program including who the program was for, what the program involved (e.g. individual

one-on-one counselling with a trained counsellor to talk about the affects of their relative’s

drinking, learn how to support non-drinking behaviour, and increase their own social and

emotional wellbeing), and when the program could be delivered. Participants were then given

part B of the survey and asked to imagine that they had a relative/friend who drank too much

who they wanted to help, before recording their opinions on the content of the CRAFT

program. Fourth, the demographic section of the survey (part C) was handed out to

participants for completion. Finally, the alcohol and drug use section of the survey (part D) was

given to participants for completion.

355

Researchers and/or Aboriginal Health Workers were present throughout the process and were

available to answer any questions from participants. The surveys were self completed;

however, assistance was provided for participants who were illiterate or had difficulty with

reading. Participation was voluntary and responses were confidential.

When the survey was administered in a group setting discussion time, facilitated by a

researcher, was given after each program survey (parts A and B). A section was provided on

the survey for participants to write down any comments they wanted to make about the

programs, serving the purpose of gaining the opinions of those who participated individually

and those who did not wish to speak in a group discussion.

Additional analysis

The proportion of participants who endorsed each response option for the survey items were

calculated. Predictors of overall acceptability of CRA and CRAFT were investigated using logistic

regression (Hosmer & Lemeshow 2000). Multinomial logistic regression (Hosmer & Lemeshow

2000) was performed to investigate predictors of the ranked session components. Predictors

included: gender; drinking status (not/at risk or high risk drinker); family member drinking

problem (no/family member with a drinking problem); and health service (Aboriginal

Community Controlled Health Service/drug and alcohol treatment agency). A difference was

statistically significant at 0.05.

Additional Results

Eight percent of participants lived alone and the others lived with up to eight other people.

When rating whether their place of usual residence met their needs, 69% endorsed a four or

five on a 5-point Likert scale (1=does not meet my needs at all, 5=meets all my needs).

356

Alcohol use. AUDIT scores ranged the capacity of the measure from zero to forty. Thirteen

percent were non-drinkers, 31% drank within recommended limits, 11% were at-risk drinkers,

and 45% were high-risk drinkers (44% not risky drinkers and 56% risky drinkers). Seventy six

percent had a family member or friend that they believed needed to cut down or stop drinking

alcohol and of those, 74% endorsed a four or five on a 5-point Likert scale to indicate that they

were worried about their family member or friend (1=not worried at all, 5=very worried).

Among at-risk and high-risk drinkers 81% could identify a family member or friend who drank

too much, this proportion was reduced to 70% for non-drinkers and those who drank within

recommended limits. Seventy percent had used tobacco in the past month. Illicit drug use was

less prevalent in the last 30 days: cannabis (29%); amphetamines (5%); cocaine (1%); heroin

(2%); and illegally obtained opioid drug (2%). The use of over the counter medications in the

past month was reported by 20% and tranquilizer use by 5%.

Community Reinforcement Approach. All presented topics of discussion for a CRA session were

endorsed as acceptable by a proportion of the sample, which varied: how much alcohol you

usually drink (86%); how you feel about your drinking (73%); what you do when you are

drinking (72%); if you cause harm to yourself and/or others when you drink (61%); setting

goals to cut down or stop drinking (93%); things (people, places, and situations) that might be

making you want to drink (64%); ways to resolve problems that might be making you want to

drink (83%); and how to use support from a trusted family member/friend to cut down or stop

drinking (88%). The role of a trusted family member/friend in a problem drinker’s treatment

was more acceptable (help you start alcohol treatment (82%), stay in alcohol treatment (89%),

and continue to drink less or stop drinking (85%)) than the role of a concerned family

member/friend (help you start alcohol treatment (80%), stay in alcohol treatment (87%), and

continue to drink less or stop drinking (84%)).

357

Using group sessions, in addition to the individual sessions, was believed to be okay by 83% to

confidentially talk to Aboriginal people with similar experiences about alcohol and its effects

on themselves and/or their family, by 92% to practice and reinforce skills learnt in one-on-one

counselling, and by 91% to participate in healthy social and recreational activities.

When participants ranked session components (1=most important, 4=least important), talking

about family member/friend drinking behaviour was the standout as most important, while

practicing how to resolve alcohol-related problem was less important (Figure 1).

Figure 1. CRA ranked session components (1=most important, 4=least important)

Community Reinforcement and Family Training. There was variation in participants’

acceptability of what they would feel okay talking to a counsellor about: how much alcohol

their relative drinks (79%); what their relative does when he/she drinks alcohol (71%); and if

their relative harms themselves or others when he/she drinks alcohol (75%).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4

Practicing how to resolve alcoholrelated problems

Learning how to reslove alcoholrelated problems

Setting goals to reduce alcoholrelated harms

Talking about your drinkingbehaviour

358

All presented topics areas for a CRAFT session were endorsed as acceptable by a proportion of

the sample, which varied: how to talk to their relative about his/her drinking (88%); ways to

talk to their relative about how alcohol is causing difficulty in their community (84%); ways to

support their relative to start treatment (89%); ways to support their relative to stay in

treatment (90%); ways to support their relative to continue to drink less (93%); ways to set

boundaries when alcohol causes difficulty in your community (91%); ways to stay strong living

in a community where alcohol causes difficulty (89%); and ways to help their community stay

strong when alcohol causes difficulty (91%).

Group sessions, in addition to one-on-one counselling, were acceptable to a proportion of the

sample in varied situations: to confidentially talk to Aboriginal people with similar experiences

about alcohol and its effects on themselves and/or their family by 85%; to practice and

reinforce skills learnt in one-on-one counselling by 89%; and to participate in health social and

recreational activities by 89%.

When participants ranked session components (1=most important, 4=least important),

practicing how to a support family member/friend to cut down or stop drinking was less

important than other session components (Figure 2).

359

Figure 2. CRAFT ranked session components (1=most important, 4=least important)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4

Practicing how to support yourfamily member/friend to cutdown or stop drinking

Learning how to support yourfamily member/friend to cutdown or stop drinking

Learning how to communicatewith your family member/friendabout his/her drinking

Talking about your familymember's/friend's drinking

360

Appendix L

Search strings for systematic search for interventions addressing problematic alcohol

use among young people

Database Search group Search terms

CDSR

ACP Journal Club

DARE

CCTR

Web of Science

Young people

(basic terms)

Young people OR youth OR adolesce$ OR young OR juvenile OR

child OR young adult

Young people --

Risk Risk OR high risk behaviour OR high risk population OR risk

factor OR reckless activity OR high risk OR risk factors OR risk

assessment

Alcohol Alcohol OR ethanol OR alcohol consumption OR alcohol

intoxication OR alcohol drinking OR alcohols

Alcohol abuse Alcohol abuse OR ethanol abuse OR alcohol dependence OR

alcoholism

Intervention

(basic terms)

Intervention OR intervention studies

Intervention --

Disruptive --

EMBASE# Young people

(basic terms)

Young people OR youth OR adolesce$ OR young

exp juvenile

Young people --

Risk Risk

exp high risk behaviour OR exp risk OR high risk population

OR exp risk factor OR exp attributable risk


exp alcohol OR exp alcohol consumption OR exp alcohol

intoxication

Alcohol abuse Alcohol abuse OR alcohol dependence

exp alcohol abuse OR alcoholism

Intervention

(basic terms)

Intervention

exp intervention study

Intervention Intervention

exp intervention study OR exp crisis intervention OR exp early

intervention OR exp early childhood intervention

Disruptive --

361

ERIC Young people

(basic terms)

Young people OR youth OR adolesce* OR young OR juvenile OR

child OR young adult

Young people --

Risk Risk OR high risk behaviour OR high risk population OR risk

factor OR reckless activity OR high risk OR risk factors OR risk

assessment

Alcohol Alcohol OR ethanol OR alcohol consumption OR alcohol

intoxication OR alcohol drinking OR alcohols


alcoholism

Intervention

(basic terms)


Intervention --

Disruptive --

ETOH Young people

(basic terms)

Adolescent

Young people --

Risk Risk / risk-taking behaviour / risk factors / prevention effort

directed at people at risk / attributable risk / high-risk group

and special population / high- risk group / high-risk youth

Alcohol Alcohol-seeking behaviour / alcohol consumption / alcohol in

any form / ethanol / alcohol intoxication

Alcohol abuse Heavy drinking OR alcohol dependence OR alcohol use disorder

OR alcohol abuse OR pathological alcohol intoxication OR

alcohol dependence

Intervention

(basic terms)

Intervention OR

Intervention Intervention OR selective prevention OR recipient of

preventive intervention OR early intervention (young children)

OR early intervention (early in disease) OR crisis intervention

OR family intervention OR peer intervention OR brief

intervention

Disruptive --

362

Medline* Young people

(basic terms)

Young people OR youth OR adolesc$ OR young

exp adolescent OR exp child OR exp young adult

Young people Young people OR youth OR adolesc$ OR young

exp adolescent OR exp child OR juvenile delinquency OR

adolescent behaviour OR exp young adult OR alcohol drinking

Risk Risk$ OR reckless activity OR risk taking behaviour OR risk

estimation OR high risk

exp risk OR exp risk-taking OR risk factors



Alcohol abuse Alcohol abuse OR ethanol abuse

exp alcohols OR exp alcoholism OR exp ethanol OR alcohol

drinking

Intervention

(basic terms)

Intervention

exp intervention studies

Intervention Intervention OR brief intervention OR minimal intervention OR

secondary intervention OR prevention OR evaluation OR

preven$ OR outcomes

exp intervention studies OR exp tertiary prevention OR exp

secondary prevention OR exp evaluation studies as Topic OR

outcome$

Disruptive Disruptive

Project CORK Young people

(basic terms)

Young adult OR adolescents

Young people --

Risk Risk OR high risk group

Alcohol Alcohol

Alcohol abuse --

Intervention

(basic terms)

Intervention

Intervention

Disruptive --

363

PsycINFO^ Young people

(basic terms)

Young people OR youth OR adolesc$ OR young

exp adolescent development OR exp juvenile delinquency

Young people --

Risk Risk

exp at risk populations OR exp risk factors OR exp risk taking

OR exp risk assessment




alcohol drinking

exp alcohols OR exp alcoholism OR exp ethanol OR drug

abuse OR alcohol abuse

Intervention

(basic terms)


exp intervention

Intervention Intervention OR intervention studies

exp intervention OR exp crisis intervention OR exp crisis

intervention services OR exp family intervention OR exp

group intervention OR exp early intervention

Disruptive --

* ‘key-words’ in lowercase, ‘MeSH’ terms in bold

^ ‘key words’ in lowercase, explode terms in bold

# ‘key-words’ in lowercase, ‘EMTREE’ terms in bold

Documents

Bianca Calabria - UNSWorks